HomeMy WebLinkAbout1708 Keel Cv - Special Inspections/Backflow - 05/12/2016CONSULTING - TESTING - SALES - REPAIRS '
INSTALLATION -EMERGENCY SERVICES
�J's Bac flow T sting .ELC
"Your Cross -Connection Conrtectfon
1540 27th Street. Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-3.56-5794
Website: ajsbackllowtesting.com E-mail: rrjsbft@enrthlink.net
Assembly.Serial #:
Y o S "3.3. q J
Test Date/Ti me:
; -1 2 -• I to', 51 As'I
Gauge Serial #:
Required Info:
_District
Tester Certification
Date Certification Expires:
5L>
Assembly Test Results: 7 PASS ❑ FAIL
-il AY .1, 7. 2016
22334
i
Backflow Prevention Device Test &Maintenance Report r t
Water District/Authority:
Facility Name:
Service Address:
Mailing Address:.
.' S Account: Contact Person:
Contact Phone:
❑ Owner ❑ Manager . ❑ Contractor ❑ Other Contact Person:
v:.
Z Company Name/Title: Contact Phone:
Mailing Address:
Make: ;Model: "76,'S Size:
Type: ❑ RPZ ❑ DC Q PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
a Date Installed: Location on Property: e.�, S r=
❑ Replacement Device Orientation Service
d:
H;. previous device serial # Inlet: Outlet: ❑ Domestic
N•
Q` 0 Vertical Up ❑ ❑ Fire
J New Installation ElVertical Down ElIrrigation
❑ Stolen ❑ Horizontal •IJ ❑ Other:
Line PSI:
?S
Check Valve #1
.: RPZ, DC, PVB, SVB
Check Valve #2
,.V RPZ, DC
Relief Valve
!d RV, RPZ
Buffer
RPZ
oa Air Inlet
:..a) Air inlet, PVB, SVB
Initial Test Results:
❑ Leak
I] Tight r'r
❑ Leak
❑ Tight
/r 7
«_ Shutoff Valve #1 1 ❑ Leak 11 Tlc
Shutoff Valve #2 1 ❑ Leak Z Tic
Assembly Concerns: Test Pr
(only if applicable)
:. ❑ Incorrect Installation ❑ ABPA
❑ Incorrect Use
Turn off date: Turn on date:
Turn off time: Turn on time:
Repaired: Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV
❑ disc ❑ sorino ❑ seat ❑ other
Ck#2
❑ disc ❑ spring ❑ seat ❑ other
RV
❑ Diaphracim ❑ seat ❑ other
Repaired:
❑ Air Inlet 711
Cleaned:
Air Inlet
Air Inlet
❑ poppet ❑ bonnet ❑ other
t
SOV #1 ❑ Open Upon Arrival Open At De
I
SOV #2 ❑ Open Upon Arrival ❑ 0 en At De
-edure:
I C1
® ASSE
Protection
❑ Containment
yi] Isolation
❑ Containment by Isolation
Re -test Results:
Tightness Differential
❑ Leak
❑ Tight
❑ Leak
❑ Tight
Backpressure exists? ❑ YES ❑ NO
4Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # /6, B-04104
Person Notified: I: '! Contacted by:
z: Turn off date/time: Turn on date/time:
A Test mKit 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 District/Authority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
d; Testing Company: Testing LLC Phone: 970452-3090 Customer Name: Phone:
(please print)) /
Tester Name: AJ Simonson Tester Signature: <:" r....-- Customer Signature:
?ackflow testers who test or repair assemblies old fire line must be registered with the Colorado Division of Fire Safety.