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Home My WebLink About5863 Northern Lights Dr - Special Inspections/Backflow - 05/20/2015CONSULTING - TESTING • SALES - REPAIRS INSTALLATION- EMERGENCYSERVICES _qp Bac Tow fisting lLC "Your Cross -Connection Connection" 1540 27th Street, Greeley, CO 80631 Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794 Website: ajsbackflowtesting.com E-mail: ajsbf aearthlink.net Assembly Serial #: I / 43 t `� 1_S,2 Test Date[Time: Gauge Serial #: a Z c-t707 3 District Required Info: Tester Certification #: 7rS0 Date Certification Expires: IA-30-r,5 Assembly Test Results: b PASS ❑ FAIL Backflow Prevention Device Test & Maintenance Report �i.1�ivkDr Water District/Authority: Account: Contact Person: c Facility Name: Contact Phone: 0 Service Address: Q Mailing Address: V❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person: CCompany Name/Title: Contact Phone: Mailing Address: Make:'' Model: 7ls Size:��' Type: ❑ RPZ ❑ DC 19 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device 2 Date Installed: Location on Property: IV, cJ a E ❑ Replacement Device Orientation Service Protection m previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment N Q fl Vertical Up ❑ El Fire .©'Isolation ENew Installation ❑ Vertical Down ❑ FrIrrigation ❑ Containment by Isolation ❑ Stolen ❑ Horizontal 'Er ❑ Other: Line PSI: Initial Test Results: Repaired: Cleaned: Re -test Results: Tightness Differential Tightness Differential ;) ❑ Ck#1 ElCk#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV Check Valve #1 ❑ Leak J Ck#1 ❑ Leak RPZ, DC, PVB, SVB ® Tight r t & ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Check Valve #2 ❑ Leak Ck#2 ❑ Leak v RPZ, DC El Tight ❑ disc El spring❑ seat El other ❑ Tight Relief Valve RV RV, RPZ ❑ Diaphragm ❑ seat ❑ other e Buffer Repaired: Cleaned: RPZ ❑ Air Inlet ❑ Air Inlet ey Air Inlet Air Inlet DI Air inlet, PVB, SVB ❑poppet ❑bonnet El other C H Shutoff Valve #1 ❑ Leak KI Tight SOV #1 ❑ O en U on Arrival ❑ O en At De arture Backpressure exists? El YES ❑ NO IT Shutoff Valve #2 ❑Leak vie Ti ht I SOV #2 ❑ Open Upon Arrival ❑ Open At Departure 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: 0) Alarm Company/Fire Department Notified: 4 Fire suppression contractor certification # IS B995 c Person Notified: ti Contacted by: z Turn off date/time: Turn on date/time: Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: I hereby certify that the isolation/ShutoffValves (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 of my ability. a; (please print) AJs Backf/Ow (please print) Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone: (please print)) AJ Simonson Tester Name: Tester Signature: Customer Signature: Backflow testers who test or repair assemblies on a fire line must be registered with the Cplorado Division of Fire Safety.