HomeMy WebLinkAbout620 SPARROW PL - SPECIAL INSPECTIONS - 7/18/2012CONSULTING -TESTING -SALES- REPAIRS
INSTALLATION- EMERGENCY SERVICES
�J'S Brad Tcrw '1 e'st-in C
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflawtesting.com E-mail: ajsbf 0eanhlink.net
Assembly Test Results: $I PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Repo
rt
Assembly Serial #:
N C094 13.7
Test DatelTime:
7- 1S- t2 y;47Aw►
Gauge Serial #:
05056084
District Required Info:
Tester Certification #:
7950
Date Certification Expires:
1/-36-11-
11772
Water District/Authority: F� to Il tas �1c-t t�la� Account: Contact Person:
Facility Name: �I ,-v rip er A60,05 Contact Phone:
Service Address: &06 <tu j eor.J F'4
Mailing Address: 5� im P
� � ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
'M Company Name/Title: Contact Phone:
Mailing Address:
Make: re /o Model: 'YES Size:
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑Other Device
Date Installed: Location on Property: 60 • S'�p a-' house /t/, 4o F C-Yi rf�
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
Q vertical Up ❑ ❑ Fire —xO isolation
i
New Installation ❑ Vertical Down ❑ i�i Irrigation El Containment by Isolation
n ❑ Stolen ❑ Horizontal ❑ Other:
'!rai
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
d
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Tightness Differential
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
°�`�
❑disc ❑ spring ❑seat ❑other
El Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
a% RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
C RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑Leak Ti ht
SOV #1 Open upon Arrival Open At Departure
Backpressure exists? ❑YES ❑ NO
cause
Shutoff Valve #2
❑ Leak ,LCJ Tight
SOV #2 ❑ open upon Arrival ❑ Open At De arture
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 #17 B995
Person Notified: A Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
'_--� I hereby certify that the isolation/shutoff Valves (SOV a 1 and SOV #2) have been returned to the position in which they were found and that the last test was done according to
Li 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.
(please print) AJs Backflow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) r
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow, testers who test or repair assemblies on -fire line must be registered with the Colorado Division of Fire Safety.