HomeMy WebLinkAbout3903 Oak Shadow Way - Special Inspections/Backflow - 07/29/2015CONSULTING -TESTING -SALES -REPAIRS .
- - INSTALLATION-El.",ERGENCVSERVICES .
93's Banl f im.�sting 1.LC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631 _
Office 970-352-3090 Cell 303-981-7032 fax 970-356-5794
Website: ajsback0pwtestino.com E-mail: ajsbft0-earthlink.netIS 'VI
Assembly Serial #: _,u 84q. 4) 3
Test Date/Time: Zy-f5 6,;09t M
Gauge Serial #: a;c75oo�'9
District Required Info:
Tester Certification #:
7SSo
Test Results:,9 PASS ❑ FAIL
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Racjcflottv.,Preverttion DeyiceTest &Maintenance Report
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3 200a
� Water District/Authority: La�-(a d Account: Contact Person:
c Facility Name: IZ -land
lJ71-oes Contact Phone:
Service Address:
Mailing Address:
L) ❑ Owner Cl Manager ❑ Contractor
❑ Other Contact Person:
2 Company NamelTitle:
Contact Phone:
0:
Mailing Address:
Make: h(a
Model: 765 Size:
Type: ❑ RPZ ❑ DC ¢' PVB
❑ SVB . ❑ Air Gap . ❑ AVB ❑ Other Device
2 Date Installed:
r
Location on Property: _��!' Sr e U-S I boo e
E ❑ Replacement Device
Orientation Service Protection
wprevious device serial #
Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire 'f'J' Isolation
p' New Installation
❑ . Vertical Down ❑ 0=lrrigation ❑ Containment by Isolation
Stolen
❑ Horizontal L7- ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#t ElCklt2 ❑ RV --T❑
Cleaned:
Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Coo
Tightness Differential
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
N3. Tight
!! G
❑ 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
c Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
ed Air Inlet
/
11 Air inlet, PVB, SVB
`'
❑ poppet ❑ bonnet ❑ other
H Shutoff Valve #1
❑ Leak
® Ticlht
SOV #1 ❑ Open Upon Arrival IRPO en At Departure Backpressure exists? a YES ❑ NO
❑Leak p Tight
Valve #2
SOV ❑ Open Upon Arrival ❑ Open At De artuae
CusShutoff
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:
4) Alarm Company/Fire Department Notified: ElFire suppression contractor certification # /SB995
o Person Notified:±_ Contacted by:
z Turn off date/time: Turn on date/time:
jg Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby rertify that the isolation/Shutoff Valves (SOV # 1 and SOV X2) 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.
(please print) AJs Backf/ow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: _ Phone:
(please print))
S
Tester Name: AJ Simonson Tester Signature: �l,% I % , Customer Signature:
Backflow testers who test or repair assemblies on a fi're'line must be registered with the Colorado Division of Fire Safety.
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