HomeMy WebLinkAbout1860 Oswego Dr - Special Inspections/Backflow - 10/01/2014CONSULTING, TESTING, SALES, REPAIRS
INSTALLATION - EMERGENCY SERVICES
nR -
- -g's Bac�OW 11 esting 11C
"Your Cross -Connection Connectims"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtestin8.com E-mail: ajsbft@eanhlink.net
Assembly Serial #:
P 83020 1
Test Date/Time:
)0-1—M )l [Z4AM
Gauge Serial #:
/9 5'o-zy—x�)f-3-r
District Required Info:
Tester Certification #:
7g50
Date Certification Expires:
Backflow Prevention Device Test & Maintenance
17912
Water District/Authority: rLCo
Account: Contact Person:
® Facility Name: Contact Phone:
y Service Address:
"? Mailing Address:
01 ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name/Title:
Contact Phone:
O Mailing Address:
Make:
Model- 7G5 Size:
Type: ❑ RPZ ❑ DC QKPVB
❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
T
Date Installed: Location on Property:
❑ Replacement Device
Orientation Service
Protection
w previous device serial #
Inlet: Outlet. ❑ Domestic
❑ Containment
a`
[Z-- Vertical Up ❑ ❑ Fire
Tirlsolation
t,PNew Installation
❑ Vertical Down ❑ P-Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
Tightness Differential
S-p
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
CheckValve #1
I
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
I9 Tight
o2r
❑ 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
Air Inlet
ail Air Inlet
!
'IT Air inlet, PVB, SVBK;
s 9
❑ poppet ❑ bonnet ❑ other
C
"y Shutoff Valve #1
El Leak
® Tight
SOV #9 C� en Upon Arrival KPO en At DepartureBackpressure exists?, El El NO
Shutoff Valve #2
❑ Leak 0 Tight
I SOV #2 Nr-ben Upon Arrival WO en At De arture Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
's Turn off date:
Turn on date:
Turn off time:
Turn on time:
U Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # / (B995
o Person Notified: Contacted by:
Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:`
1 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 6istrict/Authority shown above) and the test readings are true and accurate to the best of my ability.
.N (please print) Ads Backflow (please print)
m Testing Company: Testing LLC Phone: 970-352-3090 Custo . er Name: Phone:
H (please print))
ITester Name: AJ Simonson Tester Signature: --- Customer Signature:
Backflow testers who test or repair assemblies on a #Ire line must be registered with the Colorado Division of Fire Safety.