HomeMy WebLinkAbout2992 Denver Dr - Special Inspections/Backflow - 08/07/2014CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
A J's Bac �ow fisting LLC
"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: ajsbftC'earihlink.net
Assembly Serial #:
1 5
Test Date/Time:
8 7
Gauge Serial #:
51 S S z
District Required Info:
Tester Certification #:
9
Date Certification Expires:
10- Z•o l�r
Assembly Test Results: EkPASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
I
17347
Water District/Authority: F f` - C:., I I ' &( S Account:
Contact Person:
o Facility Name: Tom, r nIa V
4-- 1M -
Contact Phone:
0, Service Address: Z99 Z
D z A-(1/p--r D
FL c-.,, 11 ec) 5 z
a' Mailing Address;
V. ❑ Owner t, ❑ Manager ❑':Coniracfor ❑ Other
Contact Person:
CompanyAariie/Title:
Contact Phone:
Mailing Address:
Make: . (L
Model: A Size: 177 n rC F
,Type: ❑ RPZ ❑ DC I/PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: P�JO
r �.h -P- k A Pf to A c(
rip
:r ❑ Replacement Device-
Orientation -
Service - Protection
previous device serial #
Inlet: Outlet.
❑ Domestic ❑ Containment
Q
❑ Vertical Up ❑
❑ Fire ❑ Isolation
❑ New Installation
❑ Vertical Down ❑
[21rrigation ❑ Containment by Isolation
❑ Stolen
❑ Horizontal ❑
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
I 0
Tightness Differential
ElCk#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
[Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
W' Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
g RPZ
--
❑ Air Inlet
❑ Air Inlet
Air Inlet
11Air Inlet
cm Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
y Shutoff Valve#1
❑ Leak ❑ Tight
SOV #1 ❑ Open Upon Arrival ❑ Open At Departure
Backpressure exists? ❑ YES NO
Cause
Shutoff Valve"r#2
1 ❑ Leak ❑ Ti ht
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
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
c Person Notified: Contacted by:
2 Turn off.date/time: Turn on date/time:
Test Kit Make: -MhPW1I3T r' 1 Model: ''Sk Last Calibration Date: ! ` W
I hereby certify that the isolation/ShutoffValves (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
:10
the procedure shown above required by the Water DistrictlAuthority shown above) and the test readings are true and accurate to the best of my ability.(please print) AJs Backfiow(please print)
Testing Company: Testis LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) L j-4 vim: (�-'41 S
Tester Name: AZMftT6n_S0n Tester Signature: Customer Signature:
Backflowtesters who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety.