HomeMy WebLinkAbout2144 Yearling Dr - Special Inspections/Backflow - 03/20/2015CONSULTING -TESTING - SALES.- REPAIRS
INSTALLATION• EMERGENCY SERVICES
Aj's Bac f(ow Testing 11C
' "Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackilowtesting.com E-mail: ajsbft%nearthlink.net
Assembly Serial #:
I l 51555D,
Test Date/Time:
.3 2a-f5-�1;39Po>7
Gauge Serial #:
a Sve-i
District Required Info:
Tester Certification #:
71i50
Date Certification Expires:
I/ 3v7f
Assemblv Test Results: Z PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
•
J. Water DistricVAuthority: F+ lr, //ih s
Account:
Contact Person:
c Facility Name:-2 /br/-r
Contact Phone:
cci Service Address: 2 u4 Vac
-F+ G/6h s fraell, �5
<; Mailing Address:
V9 ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
Ot Mailing Address:
Make: re be.3
Model: 71
; Size: 3
Type: ❑ RPZ ❑ DC 19 PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: S c�lrrnP 0�iJ�2
g
E ❑ Replacement Device
Orientation
Service
Protection
w previous device serial #
Inlet. Outlet:
❑ Domestic
❑ Containment
a,
Vertical Up []
❑ Fire
Qlsolation
7'New Installation
❑ Vertical Down ❑
0`Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal G7!
❑ Other:
Line PSI:
Initial Test Results:
Repaired: "'
❑ Ck#1 ❑ Ck#2 ❑ Rv
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
I 1J
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1 1
❑ Leak
;RPZ, DC, PVB, SVB
d Tight
t�
❑disc ❑ spring ❑seat
❑other
❑Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
U RPZ, DC
El Tight
El disc ❑ spring ❑ seat
❑ other
❑ Tight
I Relief Valve
RV
c RV, RPZ
11
❑ Diaphragm ❑ seat
❑ other
c Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
df Air Inlet
I8
Airinlet
C Air inlet, PVB; SVB
1
❑ poppet ❑ bonnet
❑ other
ShUtOff VaIVe #1
❑ Leak 64 Tight
SOV #1 ❑ Open Upon Arrival ❑ O en At De arture
Backpressure
Cause
exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak FTi ht
SOV
#2 ❑ Open Upon Arrival ❑ Open At De arture
I Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ' ® ASSE
j ❑ Incorrect Use
1. Turn off date:
Turn on date:
E
j Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # / 5 B995
e Person Notified: LA Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
1 hereby certify that the isolation/Shutolf Valves (SOV P 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 DistricUAuthonty shown above) and the test readings are true and accurate to the best of my ability.
w (please print) AJs BackfiOw (please print)
Testing Company: Testing LLC Phone: 970-352-3090 C stomer Name: Phone:
F (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backf low testers who test or repair assemblies o , (a fire line must be registered with the Colorado Division of Fire Safety.