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HomeMy WebLinkAbout2421 Marshfield Ln - Special Inspections/Backflow - 09/16/2014CONSULTING -TESTING • SALES • REPAIRS " � INSTALLATION •EMERGENCYSEAVICES t, AJ's Bac flow Testing -PLC "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: ajsbftC'earthlink.net Assembly Serial #: Test Date/Time: Gauge Serial #: District Required Info: e! ; c3Ti S e27°7 ri-/G-/el h 31 PA� � S�Sc9oPc,', 7 Tester Certification #: 7 /Srj Date Certification Expires: If1-115--` Assembly Test Results: Q+PASS El FAIL Backflow Prevention Device Test & Maintenance 17753 Water District/Authority: rL <o Account: Contact Person: c Facility Name: Zl ourAeL, l/or4Ps Contagt Phone: Service Address: 60:�2 4 a Mailing Address: V❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person: Company Name/Title: Contact Phone: 0 1 Mailing Address: Make: I.J , le \-V5 Model: 7e) Size: 314 Type: ❑ RPZ ❑ DC p'PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device Date Installed: Location on Property: P i e),) SCE E ❑ Replacement Device Orientation Service Protection w previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment 0r' Vertical Up ❑ ❑ Fire Fisolation 93New Installation ❑ Vertical Down ❑ Q-'lnigation ❑ Containment by Isolation Stolen ❑ Horizontal ❑Q ❑ Other: Line PSI: Initial Test Results: Repaired: Cleaned: Re -test Results: Tightness Differential Tightness Differential ri ❑ Ck#t ❑ Ck#2 ElRv ❑ Ck#1 ❑ ckn2 ❑ RV Check Valve #1 ❑ Leak t Ck#1 ❑ Leak RPZ, DC, PVB, SVB Q Tight ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Check Valve #2 ❑ Leak Ck#2 ❑ Leak v RPZ, DO ❑ Tight ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Relief Valve RV RV, RPZ ❑ Diaphragm ❑ seat ❑ other Buffer Repaired: Cleaned: RPZ ❑ Air Inlet ❑ Air Inlet o6 Air Inlet Air Inlet C Air inlet, PVB, SVB ❑ poppet ❑ bonnet ❑ other y Shutoff Valve #1 ❑ Leak 2 Ti ht SOV #1 Cab en Upon Arrival ©50 en At Departure Backpressure exists? ❑ YES ❑ NO 1T Shutoff Valve #2 Cause ❑ Leak [PTight SOV #2 ❑ Open Upon Arrival ❑ Open At 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 # 14 B995 c Person Notified: t,Q Contacted by: z Turn off date/time: Turn on date/time: Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: s= / a 1-1 I hereby certify that the isolation/Shutoff Valves (SOV #1 and SOV #2) have been returned to the position in which they were found and that the fast test was done according to the procedure shown above required by the Water DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability. 0) (please print) AJs Backflow (please print) Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone: E (please print)) AJ Simonson Tester Name: Tester Signature: 4 ✓Z Customer Signature: Backflow testers who test or repair assemblies on/a fire line must be registered with the Colorado Division of Fire Safety.