HomeMy WebLinkAbout2862 Breton Way - Special Inspections/Backflow - 08/07/20144
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- CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION• EMERGENCY SERVICES
,qj'S BacL `Tow Testing LEC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631'�
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial#: C,50cj_--98
`Test DatefTime:
iGauge Serial #: 515 33z
Distf ctlRequired Info:
Tester Certification #: 1y I 1
Date Certification Expires: 10 - Ze - ? 0111
Assemblv Test Results: (APASS ❑ FAIL
Backflow�Preventlon Device Test & Maintenance Report
17027
Water District/Authonry or "C lj ;1J S Account:
Contact Person:
Facility Name: -T�IA1
[Mailing
cn-1 i �
Contact Phone:
service Address: - Z id G'L 6r
e 4 oto W &Y
FL . G 11'. ki S �.
9 %4 ZS
Address:
13 Owner ❑ Manager ❑ Contractor ❑
Other
Contact Person:
C Company Name/Title:
Contact Phone:
y Mailing Address:
Make: V.I; I V- � /.( S
Model: q 00 • A Size:
+ fv c /-I
Type: ❑ RPZ ❑ DC Q• PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: r- AS7 -S; J)r t: )(4
/r•j% V.//I (/
E'-❑ Replacement Device
Orientation
Service
Protection
previous device serial #
Inlet: Outlet:
_ ❑ Domestic
❑ Containment
a
❑ Vertical Up ❑
❑ Fire
❑ Isolation
❑ New Installation
❑ Vertical Down ❑
21rrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal ❑
❑ Other:
—1
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ C1k#2 ❑ RV
Rel-test Results:
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
7 1
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
® Tight
L l/
❑ disc ❑ spring ❑ seat
D other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
V. RPZ, DC
❑ Tight
❑ disc ❑ spring El seat
El other
❑ Tight -
W Relief Valve
RV
di RV, RPZ
❑ Diaphragm El seat
El other
ci Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
I
Air Inlet
I►r►.
OJ IAir inlet, PVB, SVB
1C
❑ poppet ❑ bonnet
❑ other
0 Shutoff Valve #1
❑ Leak ❑ Tight
SOV #1 ElOpen Upon Arrival ElOpen At De arture
Backpressure
Cause
exists? El YES El NO
H Shutoff Valve #2
❑ Leak wri ht
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
Assembly Concerns:
Test Procedure:
Comments:.
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # B995:
Verson Notified: Contacted by:
z Turn off date/time: Turn on date/time:
Test Kit Make: A19ief-i4resF- S 3 tV\ Model: BW 3S Last Calibration Date: 1— I ► I U
1 hereby certify that the isolatiordShutoff Valves (SOV # 1 and SOV #2) have been returned to the position in which they were found and that the last test was done according to
i the procedure shown above required by the Water DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
« (please print) AJs Backf ow (please print)
m Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) Sco H N1 tC 1 S
Tester Name:->AJ-6iReR9eR Tester Signature: r Customer Signature:
Backflow testers .who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety.