HomeMy WebLinkAbout1875 Fromme Prairie Way - Special Inspections/Backflow - 10/12/2015CONSULTING - TESTIA'GoSALES -RENIRS
INSTALLATION-EMERGENCYSERVICES
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"Nour Cross-Connectiort Connection'!
1540 27th Street, Greeley, CO 80631
office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowlesting.coni E-mail: njsbft0,3 earthlink.net
171K T-aw"'v-c- Q-(,("1f1Q_t_(Ja-y
_ Assembly Serial #: A r _)�V 7e ?'57
Test Date/Time: -k,3; 4
Gauge Serial 4:
District Required Info:
Tester Certification -7
Date Certification Expires: yJ
Assemblv Test Results: '19 PASS EIFAIL
Backf low Prevention Device Test & Maintenance Re
20QP 8 0
' A I Contact Person:
Water District/Authority: Account: --
Facility Name: S. Contact Phone:.
y
Service Address: Lz,ti /7—, P_rCP, el r eCl I J
r<
Mailing Address:
j
i 0 Owner 0 Manager [I Contractor El Other Contact Person:
.0
Company..NamerFitle: Contact Phone:
Mailing Address:
Model:
Make: Size:___
Type: El RPZ 0 _DC fCl PVB El SVB El Air Gap El AVB E]Dt.her Device
Date -Installed- Location on Property:
"E 111 Replacement Device Orientation: - Service. Protection
previous device serial,# Inlet, Outlet: El Domestic El Containment
2, Vertical Up 0 El Fire GE`Isolation
El New Installation 0 Vertical Down 11 -.El-lrrigation [I Containment by Isolation
i El Stolen El Horizontal E] El Other:
Line PSI:
Initial Test Results:
Repaired- TCleane'd:
D Ck#1 Ej Ck#2 El RV
0 kil kl!ti E1RV
C tj Er6'
Re-testflesults:
70 -
Tiqlhtness Differential
T iqhtness Differential
Check Valve #1
El Leak
t;
Ck#1
0 Leak
RPZ, DC, PVB, SVB
El Tight
D disc El spring El.seat El other
El Tight
Check Valve #2
0 Leak
Ck#2
El Leak
d. RPZ, DO
11 Tight,
0 disc 0 spring El seat EI other
El Tight
Relief Valve
RV
ey RV, RPZ
El Diaphraqm El seat 0 other
Buffer
Repaired:
Cleaned:
5; RPZ
El Air Inlet
El Air Inlet
.ad I Air Inlet
Air Inlet
AM Air Inlet, PvB, SvB
0 poppet El bonnet El other
Ac
a;e
Shutoff Valve #1
0 Leak 2 Tight
SOV 1-70 Open Upon Arrival tEl Open At DepartuL
Backlaressure exists? El YES E'NO
Shutoff Valve #2
Cause
El Leak f4l Tiqht
SOV PE-i Open Upon Arrival- Open At D, re re
Assembly Concerns:
Test Procedure:
(only if applicable)
F-1 Incorrect Installation
11 ABPA IM ASSE
—Comments:
z"
El Incorrect Use
Turn off date:
Turn on date:
L�uj
Turn off time:
Turn on time:
li Alarm Company/Fire Department Notified: 0 Fire suppression contractor certification # 1-5- B995
oC>
Person Notified: 11/0 Contacted by:
:Z Turn off date/time: Turn on date/time:
Test. Kit Make: Mid -West Model: 845 Last Calibration Date:
I horoby certify that the isolatlonlShutoff Valves (SOV#1 and SOV#2).havebeen returned to the position in which they wore found and that the last test was done.accordingto
the procedure shown above required by the Water DistricLIAUthOrity5hown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
Testing Company: _Testing LLC 'Phone:. 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backf low testers who test or repair assemblies or),'a fire line must be registered with the Colorado Division of Fire Safety.