HomeMy WebLinkAbout2730 Exmoor Ln - Special Inspections/Backflow - 11/12/2015CONSULTING -TESTING -SALES -REPAIRS
INSTAL LAn0N - EMERGENCY SERVICES
A3's Bac fisting LLC
fr(ow
"Your Cross-Connectfon Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
website: ajsbackflmvtestino.com E-mail: ajsbftC4'eanhlink.nct
Assembly Serial #: i 7
Test Date/Time: 0!3Ar
Gauge Serial #:
District Required Info:
Tester Certification #: % i _5
Date Certification Expires:
Assemblv Test Results: Sn PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance
21i-90
c Water District/Authority,.
Account:
Contact Person:
c Facility Name: /a: r1P y !� nt��
Contact Phone:
Service Address: 9730£YMoor L-n
":3 r5b5_-,
a Mailing Address:
V ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
G
Mailing Address:_
Make: 1i4;,+a i5
Model: ! Foo` ina Size:
Type: 'ID RPZ . _ ❑ DC ❑ PVB
❑ SVB [].Air Gap
❑ AVB ❑ Other Device
a Date Installed: Location on Property: 1y�5 �m Pn r uv ,.13
E ❑ Replacement Device
Orientation
Service
Protection
_
yprevious device serial #
Inlet: Outlet.
Domestic Containment
Q
❑ Vertical Up ❑
❑ Fire
❑ Isolation
�7 New Installation
❑ Vertical.Down ❑
❑ Irrigation
❑ Containment by Isolation
❑ Stolen
EP Horizontal 21'
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 : ❑ CkY2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 O RV
Re -test Results:
I �v
Tightness Differential
TI htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
)Z] Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
/
Ck#2
ElLeak
v RPZ, DC
Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
g
RV
RV, RPZ
°
❑ Dia hra m ❑ seat
Repaired:
❑ other
Cleaned:
Buffer
RPZ
❑ Air Inlet
Air Inlet
❑ Air Inlet
ca Air Inlet
of Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
C
Shutoff Valve #1
❑Leak
❑ Ti
O Open At Dearture Bapressure
SOV2.� Open Upon Arrival Z Open At Departure Cause
exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak it7 Tight
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turnoff time:
Turn on time:
d) Alarm Company/Fire Department Notified: El Fire suppression contractor certification # /5 B995
c Person Notified: -1 Contacted by:
z Turn off date/time: Turn on date/time:
j� Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff 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 DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
Testing Company: Tesft. LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) '- /.
Tester Name: AJ Simonson Tester Signature: ' - %%� — - Customer Signature:
Backflow testers who test or repair assemblies on.- fire line must be registered with the Colorado Division of Fire Safety.