HomeMy WebLinkAbout2308 Forecastle Dr - Special Inspections/Backflow - 09/19/2014' CONSULTING • TESTING - SALES •REPAIRS
INSTALLATION -EMERGENCY SERVICES
�[ j's Bac Tow fisting LLC
"Your Cross -Connection Connecrimi"
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
Assem*,Serial #: C9Off e) 169
Test Date/Time: 949-14 G, 0"
GaugetSerial #: e;p— � 0r
District Required Info:
Tester Certification #: -71 _nb
Date Certification Expires: 1/-3o-I S
Assemblv Test Results- iRPASS M FAIL
Backflow Prevention Device Test & Maintenance Report 17791
791
® M a s A A
Water District/Authority: �L� Account ontac�P ' s • n:
o Facility Name: o�Ae Ps o«ntact Po ne:
Service Address: PL3o"v IE-orse-ai-,/e Zr-- IFF4 e0(It 5oszz4 .
a Mailing Address: Sc _rte
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
i
0 Company Name/Title: Contact Phone:
3 Mailing Address:
j Make: Model: Tan Ft Size: 41
i Type: ❑ RPZ ❑ DC 5bPVB ❑ SVB ❑ Air Gap ❑ ❑ Other Device
rAV�B
Date Installed: Location on Property:5/ Sloe v� haJS
.�
B ❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q Or Vertical Up ❑ ❑ Fire PcIsolation
Installation ❑ Vertical Down ❑ 1�4rrigation El Containment by Isolation
�ew
tolen ❑ Horizontal 0 ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ cleat ❑ ckn2 ❑ Rv
Re test Results:
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight �
Eldisc ❑ spring El seat other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
n RPZ, DC
❑Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
W Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
E Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
�t
Air Inlet
Inlet
Air inlet, PVB, SVB
OFF
OC
❑ poppet ❑ bonnet ❑ other
y Shutoff Valve #1
❑ Leak &Ti ht
SOV #1 ❑ Open Upon Arrival E!)=0 en At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak PP -right
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
l ❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 14 B995
101 Person Notified.: Ii.1� Contacted by:
Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West- Model: 845 Last Calibration Date:gt
I hereby certify that the isolatiorvshutoff Valves (SOY #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 District'Authority shown above) and the test readings are true and accurate to the best of my ability.
a+ (please print) AJs Backflow (please print)
d Testing Company: Test/ng LLC Phone: 970-352-3090 Customer N me: Phone:
F (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on a fire ' , Must be registered with the Colorado Division of Fire Safety.