HomeMy WebLinkAbout2635 Geranium Ln - Special Inspections/Backflow - 07/06/2016CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
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"Your Cross-Comrectimt Corum-tion"
1540 27th Street. Greeley. CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajshackliowtesting.corn E-mail: ajsbfK@%earthlink.net
Assembly Serial #:
Test Date/Time:
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Gauge Serial #:
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District Required Info:
Tester Certification #:
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Date Certification Expires:
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Assembly Test Results: +.f 1 PASS ❑ FAIL
4- 31- 4C.
Backflow.Prevention Device Test &-Maintenance Report
❑ Owner 0 Manager . ❑ Contractor ❑ Other Contact Person:
2. Company Name/Title: Contact -Phone:
.0:
Mailing. Address:.
Make. _- fw:
Model: _ ,f.2P. Size:
>ii _
Type: ❑RPZ ❑ DC
PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
_......
?" Date Installed:
Location on Property: _' =-r•
E ❑ Replacement Device
Orientation
Service
Protection
m previous device serial #
Inlet: Outlet:
0 Domestic
❑ Containment
N..
'Q ,
iCf1, Vertical Up ❑
❑Fire'
,Ci" Isolation
____
[ New Installation
_ J
❑ Vertical Down ❑
,❑ Irrigation
❑ Containment by Isolation
ElStolen
❑ HorizontalLD -
❑ Other:1
- Line PSI:
Check Valve #1
RPZ, DC, PVB, SVB
Check Valve #2
V RPZ, DC
Relief Valve
�. RV, RPZ
= Buffer
RPZ
on Air Inlet
6� Air inlet, PVB, SVB
Initial Test Results:
Repaired: T.]
❑ Ck#1 i_`.Ck#2 ElRv
leaned:
Ck41 1-1 Ck#2 ❑ RV
Re -test Results:
'i htness Differential
Ti htness Differential
❑ Leak
O'Tight
1 :7
Ck#1
❑ disc ❑ spring ❑ seat ❑ other
❑ Leak
❑ Tight
❑ Leak
❑ Tight
Ck#2
❑ disc ❑ sp ring ❑ seat ❑'other
❑ Leak
❑ Tight
RV
Diaphragm ❑ seat ❑ other
Repaired:
❑ Air Inlet
Cleaned:
❑ Air Inlet
Air Inlet
N Shutoff Valve #1 1 ❑ Leak C
Shutoff Valve #2 1 ❑ Leak C'
Assembly Concerns: Test
(only if applicable)
poppet 1-1 bonnet 11
SOV #i zi -open Upon Arrival
SOV #2 ,❑ O en Upon Arrival
Jure:
❑ Incorrect Installation ❑ ABPA IM ASSE
❑ Incorrect Use.
Turn off date: Turn on date:
Turn off time: Turn on time:
At Departure Backpressure exists? ❑ YES ❑ NO
At Departure Cause
Q: Alarm Company/Fire Department Notified: ❑ . Fire suppression contractor certification B=04104 _
Person Notified: = `r' Contacted by:-
:0
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West _ Model: 845 Last Calibration Date:
1 hereby certify thatthe 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 BaClrflovtl. (please print)
u) Testing Company TeSt ag.LLC Phone: 970-352-3090 Customer Name: _ _—___.Phone: "
t" (please print)} —
Tester Name::AJ-Simon.Wh' Tester Signature:,. � '� -. —~ '�" _ . Customer Signature:
Backflow testers who test or repair assernblies'or z: fire-lirie must be registered with the Colorado Division of Fire Safetv.
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