HomeMy WebLinkAbout546 Coyote Trail Dr - Special Inspections/Backflow - 05/01/2012CONSULTING - TESTING - 54LES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
%3's Back Tow '1 ejstinq PLC
"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@eanhlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
Tester Certification #:C7
Date Certification Expires:
Assembly Test Results:W PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
10990
Water District/Authority: F4 6111 k2l=n4ol�d Account: Contact Person:
Facility Name: Contact Phone:
Service Address: '7"r51 / .Qr F-F
Mailing Address:
Ct ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: t' Model: Size: 3
Type: ❑ RPZ ❑ DC 7 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
A Date Installed: Location on Property: Side r?4' hoafe
�E ❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q Vertical Up Cl ❑ Fire �Q Isolation
New Installation El Vertical Down ❑ Irrigation ❑Containment by Isolation
❑ Stolen ❑ Horizontal? ❑ Other:
Ling PSI:
Initial Test Results:
Repaired:
❑ Ck#t ❑ ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ ck#2 ❑ RV
Re -test Results:
ipn
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
El disc El springEl seat ❑other
❑Tight
en Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
fz Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired: Cleaned:
Buffer
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
o Air Inlet
Air inlet, PVB, SVB
qt
I 1
❑ poppet ❑ bonnet ❑ other
aC
Shutoff Valve #1
❑ Leak Ti ht
SOV #1 Open Upon Arrival 0 Open At Departure Backpressure exists? ❑ YES ❑ NO
SOV #2 Open Upon Arrival 1C71 O en At Departure Cause
Shutoff V81V@ #2
❑Leak Tight
Tj Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
`❑ Incorrect Installation
❑ ABPA ® ASSE
awl, ❑ Incorrect Use
Turn off date:
Turn on date:
JTurn off time:
Turn on time:
Alarm Company/Fire Department Notified: Fire suppression contractor certification # 11 B995
ePerson Notified: /ll� Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
-11 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 DistdcNAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Cu tomer Name: Phone:
E" (please print)) \
5 Tester Name: AJ Simonson Tester Signature: / .. Customer Signature:
Backflow, testers who test or repair assemblies ofi a fire line must be registered with the Colorado Division of Fire Safety.