HomeMy WebLinkAbout5827 Big Canyon Dr - Special Inspections/Backflow - 12/12/2014CONSULTING • TESTING -SALES • REPAIRS
INSTAL LATION• EMERGENCY SERVICES
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%3 s Bac Kow ?�estinq PLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Websitc: ajsbackfiowtesting.cotn E-mail: ajsHiCearthlink.net
Assembly Serial #:
TestDate/Time:
,
Gauge Serial It:
ososcot�>
District Required Info:
Tester Certification #:
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Date Certification Expires:
// 3a /s
Assembly Test Results: OPASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
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Water District/Authority: Account: Contact Person:
e Facility Name: 2 /r 1 {-A-177P4 Contact Phone:
Service Address:
B Mailing Address:
V❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
OCompany Name/Title: Contact Phone:
Mailing Address:
i Make: Model: 7,�; s Size: Mgr
Type: -❑ RPZ ❑ DC P PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property:XI
E ❑ Replacement Device Orientation Service Protection
w previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
rn
�Sr Vertical Up ❑ ❑Fire Cs3•isolation
Kl\lew Installation ❑ Vertical Down ❑ U] irrigation ❑ Containment by Isolation
1 ❑ Stolen ❑ Horizontals ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#t ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#t ❑ Ck#2 ❑ RV
Re -test Results:
7 d
Ti htness Differential
Ti htness Differential
Check Valve 71
❑ Leak
I
Ck#1
❑ Leak
t RPZ, DC, PVB, SVB
59Tight
/I
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
w Relief Valve
RV
d RV, RPZ
❑ Diaphragm ❑ seat ❑ other
s Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
ca Air Inlet
r
Air Inlet
Qt Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
c
Shutoff Valve #1
❑Leak Q'Ti ht
SOV #1 ❑ Open Upon Arrival ❑ Open At Departure
Backpressure exists? El YES ❑ NO
Shutoff Valve #2
❑ Leak Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
j Turn off date:
Turn on date:
Turn off time:
Turn on time:
di Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #'.4 B995
c Person Notified: /iiA Contacted by:
z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
9 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 DisMct/Authodty shown above) and the test readings are true and accurate to the best of my ability.
df (please print) AJs Backflow (please print)
0 Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) /
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire. Safety.'