HomeMy WebLinkAbout1309 Leahy Dr - Special Inspections/Backflow - 06/09/2017CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
%I's Bac Tow fisting LLC
"Your Cross-Corutect uin Connection"
1540 27th Street Greeley CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax970-156-5794
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Assembly Serial #. A0114t7
Test Date/Time- C,,19A7 1:17
Gauge Serial #: rplPt;ttL
District Required Info:
Tester Certification #: 30172
Date Certification Expires- TLrmAx
Test Results
Backflow Prevention Device Test & Maintenance Report
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VEO JUN 0.9 209
Water District/Authority: Account: Contact Person-
0 Facility Name: =A W. ¢''. Nam's Contact Phone:
Service Address: 140 9 L. h jjDe rl eea 4ll� 40 16526
a Mailing Address:
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
V
C Company Nameffitle: Contact Phone:
Mailing Address:
Make: 41.00 Model Dolt 1fA Size ?4
Type: ❑ RPZ ❑ DC I(PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed Location on Property EnTb % k aF /lash
E ❑ Replacement Device Orientation Service Protection
wprevious device serial # Inl16t' Outlet. ❑ Domestic ❑ ontainment
�olation
Q CJ Vertical Up ❑ ❑ F e
❑
ew Installation ❑ Vertical Down ❑ Irrigation Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other
Line PSI:
Initial Test Results,
Repaired-
Cleaned
Re -test Results:
Tightness Differential
Ti htness Differential
65-
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ ak
Ck#1
❑ Leak
RPZ. DC, PVB, SVB
Ti ht
1.6
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
111111111
10 disc ❑ spring ❑ seat ❑ other
❑ Tight
W Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired. Cleaned
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
et1 Air Inlet
OD Air inlet. PVB, SVB
;t, (
❑ poppet ❑ bonnet ❑ other
C
H Shutoff Valve #1
1 ❑ Leak 06aht
ISOV#i OopenuponAmval ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO
I SOV #2 ❑ Open Upon Arrival ❑ Open At Departure Cause
Shutoff Valve #2
1 ❑ Leak VTight
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
a Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 17 8-04104
c Person Notified:44Contacted by:
z. Turn off date/time: Turn on date/time
Y Test Kit Make: Mid -West Model. 845 Last Calibration Date
I hereby certify that the isolattorVShutolf Valves (SOV # I 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 DisuicitAuthodty shown above) and the test readings are true and accurate to the best of my ability
n� (please print) AJs Backflow (please print)
10 Testing Company Testina LLC Phone. 970-352-3090 Customer Name Phone
(please print)) lays
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Tester Name Tester Signatul�e Customer Signature.
Backflow testers who test or repair ass ies aWiDdmust be registered with the Colorado Division of Fire Safety