HomeMy WebLinkAbout526 Muskegon Ct - Special Inspections/Backflow - 10/01/2014CONSULTING • TESTING • SALES • REPAIRS
- INSTALLATION- EMERGENCYSERVICES
913's Bad ft(ow 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: ajsbf 0aearthlink.nct
Assembly Serial #:
14 2�o) a(� G
Test Date/Time:
JO- /- !a 1l',1 AVA
Gauge Serial #:
n
District Required Info:
Tester Certification #:
-7110
Date Certification Expires:
//-3j-/5r—
Assembly Test Results: [XPASS ❑ FAIL
Backflow Prevention Device Test & Maintenance
17910
Water District/Authority: frL�y Account: Contact Person:
o3 Facility Name: Contact Phone:
Service Address: e-o/%-n 5 re oU ,- o4
Mailing Address:
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
o
Mailing Address:
Make: Model: %GS Size: 314
Type: ❑ RPZ ❑ DC FPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property:
E ❑ Replacement Device - Orientation Service Protection
w previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
Q Q Vertical Up ❑ ❑ Fire RISOIatIOn
RNew Installation ❑ Vertical Down ❑ -Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal CSP ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
S5
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
I `
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
® Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
V RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
4) RV, RPZ
❑ Diaphragm ❑ seat ❑ other
r- Buffer
Repaired:
Cleaned:
2 RPZ
❑ Air Inlet
❑ Air Inlet
ca Air Inlet
,
Air Inlet
tM Air inlet, PVB, SVB
�
t
❑poppet ❑bonnet El other
n Shutoff Valve #1
❑ Leak ElTight 1SOV#1
EFO en Upon Arrival E'Open At Departure
Backpressure exists? ❑ YES ❑ NO
F Shutoff Valve #2
Cause
❑ Leak RPTi ht
SOV #2 00en Upon Arrival D 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 # /4 B995
c Person Notified: Contacted by:
z Turn off date/time: Turn on date/time:
jt Test Kit Make: Mid -West Model: 845 Last Calibration Date:
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 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 Backf/ow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
F' (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow, testers who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety.
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