HomeMy WebLinkAbout3039 Conquest St - Special Inspections/Backflow - 07/29/2019`CONSttL 1NG - IESIING-SALES-REPAIRS t�,
<. iNSEALCA710N-EMEAGEW,savitEs , Assembly Serial #: l ?tl
c Test Date/Time: 9 f2riSr r .
Ag'S 'Bac flOiv �5t`2YtLq LLC Gauge Serial # /��o Ira
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District Required Info:
1540271h Stmll. Urceh.a CO 80631 Tester Certification #: 4140 '• _
o[tice9703523046 CeII303`18)7032 Fxx9,u35r�•s7s•t: Date Certification'Exp [Expires: 51.27
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AssemblyTest-Results: ja PASS -0,FAIL
Backflow Prevention.Device Test & Maintenance Report ' "0
0 a
WaterDistrict/Authority: ''9140 'Account: Contact Person: .
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o Facility, Name h t�1, I , tM Contact Phone
13 Service Address: .. j 7
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C Mailing Address: t
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U ❑`Owner ❑'Manager 0 Contractor D Other Contact Person:
20 Company NamelPitle: ContactPhone: I
Mailing Address:
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Make: do Model• 1) G5 Size: 1/0
Type: ❑ RPZ ❑ DC Cl-PVB " I] SVB O Air Gap D AVB ❑ Other Device -
i
a Date Installed: Location, on Property: LqI)yA 54L hctnst
S O Replacement Device Orientation Service Protection
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h' previous device serial Inlet:" Outlet: D Domestic f i Containment
m
Q - El Vertical Up C D Fire D Isolation
F }
IB New Installation D Vertical'Down" 0 T9 Irrigation' D Containment by isolation
0 Stolen 0 Horizontal f�g D Other:
Line PSI:
Initial Test Results:
'Repaired:
Cleaned:
: Re -test :Results:
❑ cktir 'O Cka2 ❑'Rv`
D Cktt1 0 ck42 ' D RV
110
Tightness Differential
Tightness Differential
Check Valve #1
D Leak,
Ck#t
0' Leak
RPZ, oC, PVB, SVe
'9 Tight
O disc D s rin D seat D<other
0 Tighi
Check
#2
D Leak
2
L7 Leak
D Tight
l disc' D spring d seat Cl-other
dD
Tight
� Relief Valve
'R
RV, li Z
is hra m [1 seat {lother
J
Buffer
Repaired:
Cleaned:
i
RPZ,.
'Q Air Inlet'
D Air Inlet
Air Inlet
Air Inlet
CP Air inlet.
poppet bonnet D other
'
c ShutoffvValve #1
'y
❑ Leak Ll Tioht
open Upon Arrival ®O en At De arture. Backpressure exists?_ li'YES' D NO
,S0V#te
1T Shutoff Valve #2
1, O Leak N Tight
sov tr2 E5 Open Upon Arrival 19 Open At -Departure Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
0 incorrect installation
❑ ABPA ® ASSE
l
D Incorrect Use
Turn off date:
Turn on date:
i
Turn off time:
Turn on tune:
^
0 Alarm' Department Notified: O • Fire suppression contractor certification #, B-04104
Iompany/Fire
+-.Person Notified`. Contactedby: f--
z Turn off dateAime: T im,on date/time:
Test Kit Maker Mid -West Model: 845 Last Calibration Date.
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'.
I hereby certify that the isolatron/shuioft Valves (SOV #i and SOV :r2) lrave'been returned to the. posiUonio,which they were found and that the Iasi test was done according to
the procedure shown above required by the Water O 16MAuthority shown above) and the test readings aretrue and accurate to the beat of my ability...
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,Q' (please print) A'Js Backflow (please print)
d Testing Company.--T.esttin4 LLC Phone: 970-3524090 Customer Name: Ptione:
} ' (Rfease print))
Tester Name• AJ Simonson Tester Signature: Customer Signature;
Backflow testers who test or repair assemblies`on a firefine must be registered with the'Colorado Division of Fire Safety.
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