HomeMy WebLinkAbout5838 Northern Lights Dr - Special Inspections/Backflow - 04/04/2015CONSULTING • TESTING • SALES • REPAIRS
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INSTALLATION• EMERGENCY SERVICES
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?{g's Bac(frow LLC
"Your Cross -Connection Connectiot"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090
Cell 303-981-7032 Fax 970-356-5794
Website: aisbackflowlesting.com E-mail: ajsbftC'earthlink.net
Assembly Serial #:
9-7 073 1 n
Test Date/Time:
/4•_4-1S- /o13Zlra^
Gauge Serial #:
r�S�Sr�f
District Required Info:
Tester Certification #:
-7 5To
Date Certification Expires:
//-3v /S
Assembly
Backf low Prevention Device Test & Maintenance
❑�
18781
c Water District/Authority: FL lol/rt. sAccount:
Contact Person:
c Facility Name: Rv /L✓
//v1r's
Contact Phone:
Service Address:
a Mailing Address:
rJ ❑ Owner ❑ Manager ❑ Contractor
❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
O
Mailing Address:
Make: FP6<o
Model:
_7to5 Size: VI)
Type: ❑ RPZ ❑ DC `5. PVB
❑ SVB ❑ Air Gap
❑ ❑ Other Device
Date Installed:
Location on Property:
IAVB
E ❑ Replacement Device
Orientation
Service
Protection
w previous device serial #
Inlet. Outlet.
❑ Domestic
❑ Containment
6
15J' Vertical Up ❑
❑ Fire
i❑`Isolation
ONew Installation
❑ Vertical Down ❑
❑%Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal 0'
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#t ❑ Ck#2 ❑ RV
Re -test Results:
Coo
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
I
Ck#i
❑ 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
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
2 RPZ
❑ Air Inlet
❑ Air Inlet
ca Air Inlet
I g
Air Inlet
Of Air inlet, PVB, SVB
C
r
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
El Leak t❑?T i ht
SOV #1 ❑ Open Upon Arrival
❑ Open At De arture
Backpressure
exists? ❑YES ❑ NO
Shutoff Valve #2
Cause
❑ Leak Q'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:
m Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 158995
e Person Notified: a'A Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolatiorVShutoH 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 DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
aa) (please print) AJs Backflow (please print)
t° Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: /.;'i �.— ✓ Customer Signature:
Backflow testers who test or repair assemblies on a fire/(ne must be registered with the Colorado Division of Fire Safety.