HomeMy WebLinkAbout534 Coyote Trail Dr - Special Inspections/Backflow - 05/08/2012CONSULTING - TESTING - SALES - REPAIRS
INVALLAT10N - EMERGENCY SERVICES
IV �[,I's B"a Tow fisting ILC
"Your Cross -Connection Connection"
1540 27th street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #: i-! C�p��zJ
Test Date/Time: �_¢j-rZ �14f3�r1
Gauge Serial #: 05o5af
District Required Info:
Tester Certification #: zf�<a
Date Certification Expires: i/-fin--2
Backf low Prevention Device Test & Maintenance Report
11002
Water District/Authority: + loh/�s�✓c d Account: Contact Person:
a Facility Name: �i� trn Pv 1 /am ps Contact Phone:
Service Address: ��4k lovo l P �-F Cn llr� S rn
Mailing Address: Scr rule r
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
'a Company Name/Title: Contact Phone:
Mailing Address:
Make: Model: Size: 7 4
Type: ❑ RPZ ❑ DC >9 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
"> ` Date Installed: Location on Property: S�iP ��7 hOL
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
A
' >91 Vertical Up ❑ ❑ Fire 'Isolation
•.k New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal 9 ❑ Other:
fi
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Tightness Differential
Ti htness Differential
V!, Check Valve #1
❑ Leak
Ck#1
❑ Leak
v RPZ, DC, PVB, SVB
Tight
o< •
El disc ❑ spring ❑ seat El other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
. RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
� Relief Valve
RV
RV,, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
c Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Air Inlet
Air iniet, PVB, SVB
/ r
❑ poppet ❑ bonnet ❑ other
fG
Shutoff Valve #1
❑ Leak kT Tight
SOV #1 Open Upon Arrival open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak Tight
SOV #2 %] open Upon Arrival Open At De arture
~I Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑'A Fire suppression contractor certification #)Z 8995
Person Notified: Alf` Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
.'� I hereby certify that the isolatioruShuloHValves (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 Distrlct/Authonly, shown above) and the test readings are true and accurate to the best or my ability.
(please print) AJs Backtlow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t" (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies,bn a fire line must be registered with the Colorado Division of Fire Safety.