HomeMy WebLinkAbout3914 Oak Shadow Way - Special Inspections/Backflow - 03/11/2015CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION -EMERGENCY SERVICES
%3's Bac§Tow fisting I.LC
"Your Cross-ConnectfonConnecrfois"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbftgeanhlink.net
Assembly.Serial #:
N 75726
Test Date/T.ime:
I/ IS 17 fypm
Gauge Serial #:
o�r1�caL39
District Required Info:
Tester Certification #:
c7!F
Date Certification Expires:
f (-36 f,S-
Assembly Test Results:
Backflow Prevention Device Test & Maintenance Report
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i Water District/Authority: �fCzdiI4s 4f �x a-c( Account: Contact Person:
c' Facility Name: ?-YIC."4 40-177P S Contact Phone:
Service Address: ?,g 14 «4 P %vll tin s c-o Puy s
a Mailing Address: Ci 1*
V} ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name/Title: Contact Phone:
®I Mailing
Address:
Make: i;�-e f)aa Model- 76 , Size: -314
3
I Type: ❑ RPZ ❑ DC OPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property:
'E ❑ Replacement Device Orientation Service Protection
` previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
ET Vertical Up ❑ ❑ Fire M�Isolation
N' New Installation ❑ Vertical Down ❑ l Irrigation El by Isolation
❑ Stolen ❑ Horizontal Q° ❑ Other:
a
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
Tightness Differential
`70
0-Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
'r
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
CPflght
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
d RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
46, Air Inlet
t g
Air Inlet
IM Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 ❑ Leak t i ht SOV #1 ❑ Open Upon Arrival ❑ Open At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 ❑ Leak Q?Ti ht SOV #2 ❑ Open Upon Arrival ❑ Open At le arture Cause
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 # IS B995
c Person Notified: A A r 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 isolationlShutoff 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 or my ability.
(please print) AJs Backflow (please print)
,d. _
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
-
Tester Name: AJ Simonson Tester Signature: a 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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