HomeMy WebLinkAbout2415 Palomino Dr - Special Inspections/Backflow - 12/16/2016CONSULTING -TESTING- SALES • REPAIRS
INSTALLATION - EMERGENCY SERVICES
91's Back &W9— sting LLC
Your Cross-Coruucrion Connection"
1540 27th Street, Greeley. CO 90631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackftouiesting.com F mail: ajsbftGearthlink.net
Assembly Serial #:
HS 9 5 C?5
Test Date/Time:
tz/r 6r I C a l o 5
Gauge Serial #:
rot 51k i k
District Required Info:
Tester Certification #:
303))
Date Certification Expires:
rzf 3o/1 R
Backflow Prevention Device Test & Maintenance Report
24685
Water District/Authority: Far+ CaILK Account: Contact Person:
c Facility Name: D& q� f- Contact Phone:
Service Address: 415 Pglorn:.e Or ro,i- roll..$ !o sosa5
a' Mailing Address:
V ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2: Company Name/Title: Contact Phone:
O'
Mailing Address:
Make: Frbr,; Model: 7a5 Size: Ri r
�
Type: ❑ RPZ ❑ DC BJ/ PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other* Device
Date Installed: Location on Property: Ls, n. 4 .,r
E❑ Replacement Device Orientation Service Protection
(a previous device serial # Inlet-- Outlet: ❑ Domestic ❑ Containment
U) �
4c Vertical Up El.�
❑moire t�-Isolation
ff New Installation ❑ Vertical Down ❑ 0 Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal 2 ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
ElCk#1 ElCk#2 El RV
FCle.,ned:
#1 ❑ Ck#2 ❑ RV
Re -test Results:
'7
Ti htness Differential
Ti htness Differential
Check Valve #1
1
Ck#t
❑ Leak
RPZ, DC, PVB, SVB
Tight
1, C
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
d RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
ca Air Inlet
CMAir inlet, PVB, SVB
p
/ , (j
❑ poppet Elbonnet El other
C
U Shutoff Valve #1 1
❑ Leak 0'Ti ht
SOV #1 ❑ Open upon Arrival ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO
❑ Leak Ti ht
Shutoff Valve #2 1
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture Cause
Assembly Concerns:
Test
Comments:
(only if applicable)
_Procedure:
❑ 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 # /t: B-04104 -
o, Person Notified: Y/a Contacted by:
z, Turn off date/time: Turn on date/time:
WILL Test Kit Make: Mid -West Model: 845 Last Calibration Date: n4ftgg I n Ir rH
I hereby certify that the isolation/Shutoff Valves (SOV At 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 DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
a) (please print) AJs BacM/OW (please print)
O' Testing Company: Testis L� LC Phone: 970-352-3090 Customer Name: Phone:
(please print)) 77;1 � l pr„J
AJ-SimOnsoh
Tester Name: Tester Signature---- Customer —r' - Customer Signature:
Backflow testers who test or repair assemblies on a fireline-must be registered with the Colorado Division of Fire Safety.