HomeMy WebLinkAbout1926 Blue Yonder Way - Special Inspections/Backflow - 06/08/2017CONSULTING - IES17NG -SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
A3's BackTow fisting I LC
"Your Cross -Connection Connection"
1530 27th Street Greeley CO 8(xi31
Office 970-352-3(M Cell 301-981.7032 Fat 970 356-5794
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Assembly Serial # 119 95 #20
Test Date[Time: EA/77 Ll'ot
Gauge Serial #: ie/srsit
District Required Info.
Tester Certification # 3o372
Date Certification Expires: rzZU4
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Backflow Prevention Device Test & Maintenance Report
26260
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c Water District/Authority: 1,t lw&i Account. Contact Person.
c Facility Name, bit Hof +nll Contact Phone
Service Address: MF all,g Y-melee 6ky Fort co PeSrS
Q Mailing Address:
rJ ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Namerritle• Contact Phone.
O
Mailing Address:
Make Fiixo Model 7cc Size.
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Type: ❑ RPZ ❑ DC 15A PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
•k. Date Installed* Location on Property 1 as r SJC of AM.-Sc
•a
E ❑ Replacement Device Orientation Service Protection
co previous device sepal # Inlet/ Outlet: ❑ Domestic ❑ S,ontainment
Q [� CL2�
Vertical Up ❑ ❑��Fire Isolation
6
New Installation ❑ Vertical Down ❑ rrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other
Line PSI:
Initial Test Results*
Repaired
Cleaned-
Re -test Results.
Tightness Differential
Ti htness Differential
❑ Ck#t ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ 1(eak
Ck#1
❑ Leak
RPZ, DC. PVB, SVB
Ti ht
1.0
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
;y RV. RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned.
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
ep Air Inlet
Air Inlet
AM Air inlet, PVB. SVB
a ]
❑ et ❑ bonnet ❑ other
C
Shutoff Valve #1
[OIL ak ErT)clht
SOV #1 ❑ Open Upon Arrival ❑ Open At De arture
Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak Ti ht
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Cause
f Assembly Concerns:
Test Procedure.
Comments-
(only if applicable)
❑ Incorrect Installation
❑ ASPA ® ASSE
❑ Incorrect Use
Turn off date
Turn on date
Turn off time
Turn on time
Alarm Company/Fire Department Notified ❑ Fire suppression contractor certification # 7 B-04104
;Person Notified- w(a Contacted 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 isolahonIShutoN 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 Distnct/Authonty shown above) and the test readings are true and accurate to the best of my ability
r (please print) AJs Backtiow (please print)
d Testing Company Testy Phone 970-352-3090 Customer Name Phone.
(Please print)) ,.rr
Tester Name A908MIDI'll-SMI Tester Signature Customer Signature•
Backflow testers who test or repair assemblie rI'a fire a ust be registered with the Colorado Division of Fire Safety.
a.`.. — - - e `. 6 _`