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HomeMy WebLinkAbout5803 Northern Lights Dr - Special Inspections/Backflow - 01/26/2016CONSULTING - TESTING - SALES - REPAIRS . INSTALLATION. -EMERGENCY SERVICES �[,�'s Bac f�°W. Tsting -CLC "YourCross-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: kjsbftCearthlink.net Assembly: Serial #: AJ.9 <G 31/3 Test Date/Time:. IAs/to 1/::10 Gauge Serial #: 1-2 1 S o 919-7 District Required Info: Tester Certification #: in3 2.2 Date Certification Expires: Assembly Test Result . ©`PASS 5V ;,AIL Backf low Prevention Device Test St Maintenance Report �/�,�j �j 2150.5. Water District/Authority: �',t /-.!/.,:4 // �vr/, _ Account: Contact Person: c Facility Name: Contact Phone: v Service Address: 6-Re 3 Na.)Ae% Mailing Address: U ❑ Owner. ❑ Manager. 0 Contractor ❑ Other Contact Person: 2 Company Name/Title: .. Contact Phone: 0 Mailing Address: Make Model.:. `7G 9 Size: ..Type:. ❑ RPZ ❑ DC ©PVB ❑ SVB ❑ Air Gap ❑ AVB. ❑ Other Device Z' Date Installed: Location on Property: Sf 5'Ad i 1„aor E ❑Replacement Device Orientation Service Protection H. previous device serial # Inlet- Outlet: ❑ Domestic ❑ Containment Q , Vertical Up ❑ ❑ Fire ❑ Isolation IJ New Installation ❑ Vertical Down ❑ 91,1frrigation ❑ Containment by Isolation ❑ Stolen ❑ Horizontal Cif ❑ Other: Line PSI: Initial Test Results: Repaired: Cleaned: Re -test Results: ❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV Tightness Differential Ti htness Differential Check Valve #1 RPZ, DC, PVB, SVB ❑ Leak ❑t /fight• Ck#1 ❑ disc ❑ spring ❑ seat ❑ other El Leak ❑ Tight Check Valve #2 ❑ Leak Ck#2 ❑Leak RPZ, DC ❑ Tight ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Relief Valve RV RV, RPZ ❑ Dia hra m ❑ seat ❑ other Buffer Repaired: Cleaned: RPZ ❑ Air Inlet ❑ Air Inlet ca Air Inlet Air Inlet C Air inlet, PVB, SVB. y ❑ poppet ❑ bonnet ❑ other n Shutoff Valve #1 ❑ Leak ❑ Ti ht SOV #1 ❑ Open Upon Arrival ❑ Open At Departure . Backpressure exists? ❑ YES El. NO Shutoff Valve #2 ❑ Leak ❑ Tight SOV #2 ❑ Open Upon Arrival ❑ Open At De 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 # /E B995 Person Notified: A11A Contacted by: z Turn off date/time: Turn on date/time: Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: 1 Z ?a_Z2r 1 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. 0 (please print) AJs Backflow. .. (please print) d Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone: E'. (please print)) Tester Name: AJ Simonson Tester Signatur _���_ �� Customer Signature: " Backflow testers who test or repair asse �bjrbl es-6n -;rfre Iine_must be registered with the Colorado Division of Fire Safety.