HomeMy WebLinkAbout426 Noquet Ct - Special Inspections/Backflow - 04/20/2014AIMING - 7FST1W'-1S4LES - REPAIRS
Zot INSTALLATION-EMEROBI C.YYSERVICES
JW AI's Bac6Jlf -" '1 jesting LEC
"Your Cross-Coroucdon Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981.7032 Fax 970-356-5794
. Website: ajsbackflowtesfing.com E-mail: ajOft@earthlinknet
Assembly Serial #:
Gq;:kq Ici
Test DatelTime:
d Zo-(9` /o S4A+n
Gauge Serial #:
oz�0zoz�
District Required Info:
Tester Certification #:
7 jf n
Date Certification Expires:
Assembly Test Results: RI PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
16127
Water District/Authority: V•L,- D Account: Contact Person:
Facility Name: Free 1— Contact Phone:
Service Address: 42 L A1,, l ry S rn 4-)5�7_4
Mailing Address: 4c7 ape
❑ Owner ❑ Manager❑,;Contractor ❑ Other Contact Person:
V
Company Name/Title: Contact Phone:
Mailing Address:
Make: '-'' ��% Model: '765 Size:
Type: ❑ M& r9 DC�� �PYBt'(d j 20 SVB ❑ Air Gap ❑ AVB ❑ Other Device
3
t
� Date Installed: Lgeation on P�erty: ��7, SIc1e o-F 6,00 S2
❑ Replacemen'n,Dievi7 � - t Orieritation Service Protection
previous device sepal A Inlet: } Outlet. ❑ Domestic ❑Containment
Vertical Up ❑ ❑ Fire q;i+tsolation
New Installation ❑ Vertical Down ❑ PIrrigation ❑ Containment by Isolation
❑ Stolen i ❑ Horizontal ❑ Other:
Line PSI:.
Initial Test Results:
Repaired
❑ Ck#1.--❑,Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑.RV
Re -test Results:
-Ti hthb§s . Differential
Tightness Differential
Check Valve #1
❑ Leak
A
�t`�
Ck#I }
`
❑ Leak
RPZ, DC, PVB, SVB
X Tight
nip
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve'42
L k
Ck#2
❑ Leak
. RPZ, Dc
❑ Tight
❑ disc Uspring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Dia hra m ❑ seat ❑ other -
Repaired:
Cleaned:
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
G
Air Inlet
Air inlet, PVB, SVB
C
,❑ poppet ❑ bonnet ❑ other
+�. Shutoff VaIVe #1
❑ Leak Ti ht
SOV #1 in Open Upon Arrival O en At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak Tight
SOV #2 [,:]-Open Upon Arrival O en Al 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 # 1.4B995
Person Notified: A44 Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: -3-/h-14
1 hereby certify that the isolation/ShutoffValves (SOV #f 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 DistricUAuthonty shown above) and the test readings are true and accurate to the best of my ability. -
j (please print) AJs Bacidiow (please print)
0 (rob Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
f (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on , i e line must be registered with the Colorado Division of Fire Safety.