Loading...
HomeMy WebLinkAbout2027 Yearling Dr - Special Inspections/Backflow - 02/19/2015CONSULTING •TESTING • SALES • REPAIRS INSTALLATION • EMERGENCYSERVICES Sfi.`i: M's Bac fGow '1 ESting .Ef-C 4` .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: ajsbft@earthlink.net Assembly Serial #: P 7[7d 5"17 � Test DatelTime: 7-- Iy-/S 8! 4o Fel Gauge Serial #: 0 � U �nrrY �i District Required Info: Tester Certification #: 7 1.'50 Date Certification Expires: 1/-3�-/� Assembly Test Results: f,?7)PASS ❑ FAIL Backflow Prevention Device Test & Maintenance Report • • Ia Water District/Authority: rolltk� Account: Contact Person: c Facility Name: Al r I1Z Contact Phone: Service Address: a Mailing Address: ' V� ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person: 2 Company Name/Title: Contact Phone: O Mailing Address: Make: Fe- .(teo Model: 1l 5 Size: 3/li Type: ❑ RPZ ❑ DC ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device /KPVB 2 Date Installed: Location on Property: ill lei v!P! CJ�>�ySP M W. ❑ Replacement Device Orientation Service Protection w previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment `'tfs F' Vertical Up ❑ ❑ Fire 8' Isolation ! New Installation ❑ Vertical Down ❑ [Irrigation ❑ Containment by Isolation Stolen 6 ❑ Horizontal E311 ❑ Other: Line PSI: Initial Test Results: Repaired: ❑ Ck#t ❑ Ck#2 ❑ RV Cleaned: ❑ Ck#1 ❑ Ck#2 ❑ RV Re -test Results: If Tightness Differential Tightness Differential Check Valve #1 ❑ Leak Ck#1 ❑ Leak RPZ, DC, PVB, SVB (01 Tight 1,4 ❑ 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 Buffer Repaired: Cleaned: RPZ ❑ Air Inlet ❑ Air Inlet ca Air Inlet g Air Inlet = Air inlet, PVB, SVB ' ❑ poppet ❑ bonnet ❑ other ti Shutoff Valve #1 ❑Leak ©Ti ht SOV #1 ❑ Open Upon Arrival ❑ Open At De arture Backpressure exists? DYES ❑ NO Cause Shutoff Valve #2 ❑ Leak I9'Ti ht SOV #2 ❑ Open Upon Arrival ❑ Open At De arture 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 # e B995 c Person Notified: A Contacted by: Turn off date/time: Turn on date/time: jG Test Kit Make: Mid -West Model: 845 Last Calibration Date: S/e0L/ ( 1 hereby certify that the isolation/Shutoff Valves (SOV Nl and SOV #2) have been returned to the position inwhich they were found and that the last test was done according to I the procedure shown above required by the Water DistricUAuthority shownabove) and the test readings are true and accurate to the best or my ability. (please print) AJs Backfiow (please print) y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone: t (please print)) Tester Name: AJ Simonson Tester Signature: 4 IIZL � Customer Signature: Backflow testers who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety.