HomeMy WebLinkAbout433 Noquet Ct - Special Inspections/Backflow - 07/21/2014E
CONSULTING • TESTING - SALES - REPAIRS
I NSTAL L AT(ON - EMERGENCY
SERVICES
Ays Bac Tow.'1 Esdna 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@eanhlink.net
" Assembly Serial #:
N1(00 2- Lf D
TestDate/Time:
7-2-I'IL/ I:/5
Gauge Serial #:
51S33Z
District Required Info:
Tester Certification #:
10180
Date Certification Expires:
10 - Z O - Z O I t-I
Assembly Test Results: 13 PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
17007
Water District/Authority: F LCZ Account: Contact Person:
c Facility Name: _ E Kl�� 1 l= S Contact Phone:
Service Address: y 33 ti u(:JU C'I- C T FT Loll;0& CD 8C) 5z4
Mailing Address:
O❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
d
Z Company Name/Title: Contact Phone:
Mailing Address:
Make: F E P7,L.o Model: %, %S Size: �i .A(( N
Type: ❑ RPZ ❑ DC IXPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
K� Date Installed: Location on Property: CA5_T e XA-� ;Qr WA I
a
E ❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q P!P Vertical Up ❑ ❑ Fire ,Isolation
New Installation ElVertical Down ❑ 2Qrrigation ElContainment by Isolation
a
❑ Stolen ❑ Horizontal t* ❑ Other:
Line PSI:
Initial Test Results:
Repaired: Cleaned:
Re -test Results:
50
11 Check Valve #1
❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV
Ck#1
Tightness Differential
ElLeak
Tightness Differential
❑
Q
Leak
aa RPZ, DC, PVB, SVB
LYTight
❑ disc ❑ swing ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
.
Ck#2
❑ Leak
RPZ, DC
❑Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
W Relief Valve
RV
d RV, RPZ
❑ Dia hra m ❑ seat ❑ other
i Buffer
Repaired: Cleaned:
RPz
❑ Air Inlet ❑ Air Inlet
Air Inlet
q
Air Inlet
CAir inlet, PVB, SVB
I o (J
❑ poppet ❑ bonnet ❑ other
ey Shutoff Valve #1 1 ❑ Leak ❑ Ti ht SOV #1 UPOpen Upon Arrival FrrOpen At Departure Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 ❑ Leak aTight SOV #2 O en Upon Arrival Open At De arture Cause
Assembly Concerns: Test Procedure: Comments:
°a (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 B995
Notified: /l� Contacted by:
Z1Person
Turn off date/time: Turn on date/time:: J
Y Test Kit Make: Mm4wMSM Model: ii5 -35 Last Calibration Date:
1 hereby certify that the isolatiorVShutoN Valves (SOV At 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 DishlcbAuthonly shown above) and the test readings are true and accurate to the best of my ability.
w (please print) Ads Backf ow (please print)
m Testing Company: Testima LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) SL-O
Tester Name: AJOhnonser, Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety.