HomeMy WebLinkAbout563 San Juan Dr - Special Inspections/Backflow - 05/07/20129703305357 Journey Homes
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r"'j. BQG �Si L11g LLC
-your Goss Cmmrction Connectlmr^
1540 nth sneer, Greeley, Co aow i
Office 970-352-3090 Cell 303.981-7032 Fax 970-356.3794
website: a isbackflowtestingcom E-mail: eisbfr@anhlinLnet
03:47:07 p.m. 05-08-2012
Assembly Serial #: A( C'4e_453
Test Date/Time: rl g zoAi»
Gauge Serial #: g�a4ryt'AI
District Required Info: !„ i
Tester Certification #: 7grjy) 12„b() J
Date Certification Upires:
Assembly Test Results: PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
10991
Water DistrictlAuthority: F J (ll �,�1.e,4 Account: Contact Person:
UN
Facility Name: e 6f, 4015, Contact Phone:
Service Address: 7 ; r bn IN-
Malling Address:
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: Model: ;2yae- Size: 3/4
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: / Location on Property: ' P
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire Isolation
New Installation ❑ Vertical Down ❑ F Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Tightness Differential
Tightness Differential
Check Valve #1
RPZ, DC, PVB, SVB
❑ Leak
Tight
o1, `t�/
Ck#1
❑ disc ❑ spring ❑ seat ❑ other
❑ Leak
❑ 71ght
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ ht
❑ disc ❑ song ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air inlet, PVB, SVB
la
Air Inlet
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑Leak hl
SOV #1 gopen Upon Arrival Open At De rture
Backpressure existsl ❑YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak right
SOV #2 Open Upon Arrival Open At Departure
Assembly Concerns:
TOW Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
t I Turn off date:
Turn on date:
Turnoff time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # I B995
Person Notified: AA Contacted by:
Turn off datettime: Turn on dalettime:
Test Kit Make: Mid�West Model: M Last Calibration Date:
1.1 1 hereby car* that tire Isolatror✓Shumtl Vahes (SOY # i and SOV #2) have been returned to the position In which they were round and that the rant test was done accrording to
the procedwe shown abovw regrilied by the We ter Diabkt/Audwity shown above) and the test readings are true and accurate to the best 0f my ability,
(please print) AJs Back/low (please print)
Testing Company: Testlns>! LLC Phone: 970-W2-30W Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Baddlow testers who test or repair assemblies onA fire line must be registered with the.Colorado Division of Fire Safety.