HomeMy WebLinkAbout2221 Milton Ln - Special Inspections/Backflow - 06/17/2014CONSULTING •TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
sm
_qys Bac flow Testing LLC
1
'Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtestin8.com E-mail: ajsbft@eanhlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #: n x ca �7c�kD 845
District Required Info:
Tester Certification #:
Date Certification Expires:
Backflow Prevention Device Test & Maintenance Report
lI-5v75"-
c Water District/Authority:
Account:
Contact Person:
c Facility Name:
Contact Phone:
Service Address: .?.2.2 ) n1'
-�00 211 r-1 !// L, ��
?a4✓�
Mailing Address:/71,0
V ❑ Owner ❑ Manager ❑ Contractor
❑ Other
Contact Person:
® Company Name/Title:
Contact Phone:
Mailing Address:
Make: tc'. �,us
Model:
7�u ^ Size: Y4
Type: ❑ RPZ ❑ DC �DPVB
❑ SVB ❑ Air Gap
❑ AVB El Other Device
Date Installed:
Location on Property: S
.O
E ❑ Replacement Device
Orientation
Service
Protection
wprevious device serial #
Inlet: Outlet:
El Domestic
❑ Containment
Q
❑' Vertical Up ❑
❑ Fire
Eklsolation
New Installation
❑ Vertical Down ❑
P-irrigation
❑ Containment by Isolation
Stolen
❑ Horizontal 1119
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
S�
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
,[J Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
ea Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
ailf Air Inlet
�` 0
Air Inlet
IM Air inlet, PVB, SVB
c
❑ poppet ❑ bonnet
❑ other
y Shutoff Valve #1
❑ Leak OTi ht
SOV #1 L Open Upon Arrival N'O en At De arture
Backpressure exists? ❑ YES El NO
Shutoff Valve #2
❑ Leak a Tight
SOV #2 ElOpen Upon Arrival �❑ Open At De arture
Cause
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:
0 Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # L4 B995
c Person Notified: AA Contacted by:
Z Turn off date/time: Turn on date/time:
j� Test Kit Make: Mid -West Model: 845 Last Calibration Date: .S-
I hereby certify that the. isolation/Shuto#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
L the procedure shown above required by the Water District/Authority shown above) and the test readings are true and accurate to the best of my ability.
0) (please print) AJs Backflow (please print)
00 Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
F (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety-