HomeMy WebLinkAbout557 San Juan Dr - Special Inspections/Backflow - 05/08/2012 (2)CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
AJ's Bac Tow Testing 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: ajsbft@earthlink.net
Assembly Serial #: H G.774;9
Test Date/Time: S 9-Iz 170
Gauge Serial #: oSn!gV84
District Required Info:
Tester Certification #: ` 6r 0
Date Certification Expires: H-SO-12
Z PASS ❑ FAIL
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Backflow Prevention Device Test & Maintenance Report
Water District/Authority: + e l/, l.c/Lou'�a..cJ Account: Contact Person:
3 Facility Name: �osnr P y /%raIPS Contact Phone:
Service Address: - yr �1`c a r, L F4 rol�.ti s rc)
Mailing Address: `i(t/s/P
V ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: re e-o Model: 7�S Size:
Type: ❑ RPZ ❑ DC ;I PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
I
Date Installed: Location on Property: Gil, S �P r�tadS�
,15 ❑ Replacement Device Orientation Service Protection
y
'v! previous device serial # Inlet: Outlet. ❑ Domestic Containment
�❑
Q )i❑ Vertical Up ❑ ❑ Fire /,-, Isolation
New Installation ❑ Vertical Down ❑ >,n Irrigation ❑ Containment by Isolation
ElStolen ❑ Horizontall El Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Ti htness Differential
Tightness Differential
f
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
a► RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
r- Relief Valve
RV
!� RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired: Cleaned:
Buffer
RPZ
❑ Air Inlet ❑ Air Inlet
o Air Inlet
/ 8
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 1 ❑ Leak Tight SOV #1 )0 Open Upon Arrival i,a Open At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 1 O Leak Tight SOV #2AD open Upon Arrival 10 Open At Departure 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:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #) 7- B995
Person Notified: Contacted by:
Z Turn off date/time: Turn on date/time:
I
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 DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
gTester Name: AJ Simonson Tester Si nature: Customer Signature:
g ZZZZ
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety.
II