HomeMy WebLinkAbout609 SPARROW PL - SPECIAL INSPECTIONS - 8/30/2012CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION -EMERGENCY SERVICES Assembly Serial #:
Test DatefTime:
1{�'s BCiG Ow �stircg ifC Gauge Serial #:
-Your Cross -Connection Connection" District Required Info:
154027th Street, Greeley, CO 80631 Tester Certification #:
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794 Date Certification Expires:
Website: ajsbackfiowtesting.com E-mail: ajsbft9eanhlink.net p
Assembly Test Rest.
Backf low Prevention Device Test & Maintenance Re
7g50
12171
Water District/Authority: T 4 Calltas
)Zo_>P Urd Account:
Contact Person:
3 Facility Name: :oc r-rrV 1 6M,-5
$- r-,<Dq f,t-s
Contact Phone:
Service Address: r
a , ,> 01 4- (61
eo
Mailing Address: -S4Lntb
rJl ❑ Owner ❑ Manager ❑ Contractor
❑ Other
Contact Person:
2 Company Name/Title:
Contact Phone:
0�
Mailing Address:
Make: bco
Model:
765 Size: 314
Type: ❑ RPZ ❑ DC PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
/�S
a' Date Installed:
Location on Property: Zt Sick d-lF' A0C2S P
m ❑ Replacement Device
Orientation
Service
Protection
previous device serial #
Inlet: Outlet.
❑ Domestic
❑ Containment
'`2
�E Vertical Up El
❑ Fire -�)Isolation
i)CJ New Installation
❑ Vertical Down ❑
9-Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal �l
El Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ C1k#2 ❑ RV
Ti htness Differential
Check Valve #1
❑ Leak
6
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
El disc ❑ spring El seat
El other
❑Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
d RV, RPZ
ElDiaphragm El seat
El other
c Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
oti Air Inlet
S
Air Inlet
O) Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
C
Shutoff Valve #1
1 ❑ Leak Tight
SOV #1 ❑ Open Upon Arrival open At Departure
Backpressure
Cause
exists? ❑ YES ❑ NO
H Shutoff Valve #2
1 ❑ Leak Ti ht
SOV #2 ❑ 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 #12 B995
c Person Notified: A44 Contacted by:
Z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolatiorVShutoff 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.
+`Nr (please print) AJs Backt/ow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t (please print))
Tester Name:. AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies/on a fire line must be registered with the Colorado Division of Fire Safety.