HomeMy WebLinkAbout5744 Big Canyon Dr - Special Inspections/Backflow - 08/22/2016CONSULTING - TESTING%SALES - REPAIRS
INSTALLATION -EMERGENCY SERVICES
1t,q's .Bac flawstirig.I�C
"Your Cross-Cdnnection 6intection"
1540 27th Street. Greeley- CO 80631
Office 970-352-3090 r Cell 303-981-7032 Fax 970-356-5794
Website:
ajsbackflywtestin&corn E-mail: njsbft@earthlink.net
Assembly Serial #:
Test Date/Time:
�7 . 7 ' =
Gauge Serial #-
District Required Info:
Tester Certification #:
;;:;
Date Certification Expires:.
ir_ ;;; i
Assembly Test Results:zEl PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
Water District/Authority: ;" r''.:. ;=.; : :. Account: Contact Person:'
Facilit Name:. i':,; r;.- ti
®, y _—_ Contact Phone:
�. Service- Address: S`-744. t.. ;.,>�,.>,T i), 4fa- . r; �; . - r!n f,)-T
Q Mailing Address::
❑ Owner. ❑ Manager. . ❑ Contractor - ❑ Other ___- Contact Person:
2 . Company Name/Title: _ Contact. Phone:
O
Mailing Address:
Make; ° (n�: a
Model: -71-L.7
Size: -�
Type: ❑ RPZ ❑ DC 0 PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device __-
Date Installed: _ -
Location on Propertji: �; •1
t�
_.=•_r_..�=f
--- ...._-....---....... ................. -_... _......... — ..... _._..— ---
E ❑ Replacement Device
Orientation
Service
Protection
w previous device serial #
Inlet: Outlet:
❑ Domestic
❑ Containment
,CI Vertical Up ❑
❑ Fire
l Isolation
�❑ New Installation
❑ Vertical -Down ❑l
Irrigation
C1.Containlnent by Isolation
❑ Stolen
❑ Horizontal /D
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 RV
Cleaned:
k Ck#2 ❑ RV
Re -test Results:
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
C Leak
RPZ, DC, PVB, SVB
,E� Tight
11 ✓
❑ disc ❑ spring ❑ seat ❑ other
.
❑ Tight
Check Valve #2
❑ Leak
C1r#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned:
RPZ
0 Air Inlet
❑ Air Inlet
Air Inlet
�
Air Inlet
1 Air inlet, PVB, SVB
::
El poppet El bonnet ❑ other
Shutoff Valve #1
❑ .Leak f❑ Tight
SOV #t ❑ Open Upon Arrival ❑ Open At De arture
Backpressure exists? YE ❑ NO
u
Valve #2
❑ Leak r❑ Tight
SOV
❑ Open Upon Arrival ❑ Open At Departure
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.#f(, B-04104 _
Person Notified: Contacted by:
Z Turn off date/time: _..:__. Turn on date/time:
2 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 District/Authority shown above) and the test readings are true and accurate to the best of my ability.
(please print) Ads Backfiow (please print)
Testing Company: TestingLC Phone: 970-352-3090 . Customer Name: Phone:
F" (please print)) ! ! — —
Tester Name: AJ Simonson_ Tester Signature: _ -- _ Customer Signature:—
Backflow testers who test or repair assemblies oh a fire line must be registered with the Colorado Division of Fire Safety.