HomeMy WebLinkAbout7015 Autumn Ridge Dr - Special Inspections/Backflow - 07/13/2012i'�
CONSULTING • TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
,Ts B"c Tc fisting 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: ajsbfiecarthlink.net
Assembly Serial #: H Co79FW
TestDate/Time: -71'3-1Z 6, 54m
Gauge Serial #: 0��0089
District Required Info:
Tester Certification #:
Date Certification Expires: // io-/Z
Assemblv Test Results: V5 PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
11729
Water District/Authority: f + l.r.,T�l �S�Lcx.�fac� Account: Contact Person:
? Facility Name: JC.] Y nY r s Contact Phone:
Service Address: 015 1),34r, w t� k
Mailing Address: <G M e
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
17 Company Name/Title: Contact Phone:
Mailing Address:
t~i� E7ro Model: 74 4 Size: 3%4
kIMake:
Type: ❑ RPZ ❑ DC El ❑SVB ❑Air Gap AVB El Other Device
Date Installed: Location on Property: S
b Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet. ❑ Domestic ❑Containment
f�J Vertical Up ❑ ❑Fire 111" Isolation
New Installation ❑ Vertical Down ❑ /Z Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
Tightness Differential
U
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
5 Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
• Tight'
❑disc ❑ spring ❑seat ❑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:
Buffer
RPZ
l S
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
3C
1 + Shutoff Valve #1
[OIL ak Tight
SOV #1 ❑ Open Upon Arrival A Open At De arture Backpressure exists? ❑ YES ❑ NO
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure Cause
Shutoff Valve #2
❑ Leak Tight
Assembly Concerns:
Test Procedure:
Comments:
I (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 #/Z B995
.❑.n
Person Notified: /i#1 Contacted by:
Turn off date/time: Turn on date/time-
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff Valves (SOV if 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 BBCMIOW (please print)
ilfl
0Testing Company: Testing LLC Phone: 970-352-3090 Cu tomer Name: Phone:
F" (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies gKa fire line must be registered with the Colorado Division of Fire Safety.