HomeMy WebLinkAbout556 San Juan Dr - Special Inspections/Backflow - 07/06/2012CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
.qj's Ba.e Tow Te'sting LEC
"?''our Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbfl0earthIink.nct
Assembly Serial #: 14 0.,77!T
Test Date/Time: :Z_6- 17 /'4
Gauge Serial #: o 5 0 cTno R I'
District Required Info:
Tester Certification #: !2525-Z-)
Date Certification Expires: fit:-
,o ( 7-
Assembly Test Results: J6 PASS El FAIL
Baclill Prevention Device Test & Maintenance Report
11597
Water District/Authority: j&bAccount: Contact Person:
Facility Name: 'Z7_rxrA 04 t-Aw e r Contact Phone:
'
Service Address: C5 .<tf ' 12 Dj- 11114 6 eo;--)
50 Mailing Address: me
0 Owner 0 Manager 0 Contractor El Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: Model: 744 Size:
Type: El RPZ 0 DC ;9 PVB 0 SVB 0 Air Gap 0 AV13 0 Other Device
Date Installed: Location on Pro pertv:Sr
0 Replacement Device Orientation Service Protection
previous device serial If Inlet: Outlet. 1:1 Domestic [I Containment
Vertical Up C-1 11 Fire )Olsolation
ew Installation 11 Vertical Down [3 >?Irrigation 0 Containment by Isolation
11 Stolen 11 Horizontal 1:1 Other:
Line PSI:
Initial Test Results:
Repaired:
El Ck#1 11 Ck#2 13 RV
C11e
Cleaned:
0 Ck#1 0 Ck#2 0 RV
0 C
Re test Results:
:Iii C�o
Tiqhtness Differential
Tiqhtness Differential
m Check Valve #1
11 Leak
Ck#1
0 Leak
RPZ, DC, PVB, SVB
Tight
D disc 0 spring 0 seat El other
.*U Check Valve #2
1:1 Leak
Ck#2
El Leak
RPZ, DC
1:1 disc C3 spring 0 seat 11 other
11 Tight
Relief Valve
RV
RV, RPZ
El Diaphragm 11 seat C3 other
Repaired:
Cleaned:
Buffer
RPZ
C1 Air Inlet
0 Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
D<<
C3 poppet 0 bonnet El other
C Shutoff Valve #1
101 Leak Tight
SOV #1 *0 Open Upon Arrival XOPen At Departure
Backpressure exists? El YES 0 NO
Cause
Shutoff Valve #2
❑Leak 'J9 Tight
SOV #2 El Open Upon Arrival 'CJ Open At De arture
Assembly Concerns:
T6st Procedure:
Comments:
(only if applicable)
El Incorrect Installation
0 ABPA IM ASSE
C3 Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: 0 Fire suppression contractor certification # P B995
Person Notified: PA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: 5t� is
I hereby certify that the isolationIShutoff Valves (SOV #I 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.
(please print) AJs Backfidw (please print)
Testing Company: Testing LLC Phone: 970-352-3090 mer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: z�12_ Customer Signature:
Backillow testers who test or repair assemblies oryi fire line must be registered with the Colorado Division of Fire Safety.