HomeMy WebLinkAbout2415 Forecastle Dr - Special Inspections/Backflow - 09/30/2014CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
A3's Bacgow fisting LLC
Your Cross-CannectwnConnection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtestin8.com E-mail: ajsbft@earthlink.net
Assembly Serial #: (::� is
Test Date/Time:gi-3u
Gauge Serial #: OSc=
District Required Info:
Tester Certification #: %`%
Date Certification Expires:
AccPmhlvTact RP.6ittltR' F] PARR n FAII
Backf low Prevention Device Test & Maintenance Report
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17894
c Water District/Authority: r Lr i
Account:
Contact Person:
Z Facility Name:
Contact Phone:
0 Service Address: g41S" -�v eccas-1
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'Q Mailing Address:
U ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
2 Company Name/Title:
Contact Phone:
Mailing Address:
Make:
Model:
Size:
Type: ❑ RPZ ❑ DC ❑ PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
?` Date Installed: Location on Property:
❑ Replacement Device
Orientation
Service
Protection
previous device serial #
Inlet: Outlet:
❑ Domestic
❑ Containment
❑ Vertical Up ❑
❑ Fire
❑ Isolation
❑ New Installation
❑ Vertical Down ❑
El Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal D
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Ti htness Differential
Ti htness Differential
ElCk#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ Rv
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
[9Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
Rv, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
gRPZ
❑ Air Inlet
❑ Air Inlet
a Air Inlet
Air Inlet
IM Air inlet, PVB, SVB
I ❑ poppet ❑ bonnet
❑ other
C
*` Shutoff Valve #1
❑ Leak a Ti ht
SOV #1 ❑ Open Upon Arrival Q Open At Departure
Backpressure exists? ❑ YES ❑ NO
❑ Leak 63 Ti ht
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Shutoff Valve #2
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 # B995
Person Notified: Contacted by:
Turn off date/time: Turn on date/time:
X Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff 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
''. the procedure shown above required by the Water Distdct/Authonly shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJS BaCM/ow (please print)
m Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety.