HomeMy WebLinkAbout615 SPARROW PL - SPECIAL INSPECTIONS - 9/29/2012c0661aIMIS • Inn#S•s41F3 • REMRS
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Aj's Bac�ow'Testing LLC
"Your Cross-Carmect Im% Cminwhon"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
wehaite: ajsbackflowtesting.mm E-mail: ajsbft@eenhlinknd
Assembly Serial #: P to 6
Test Date/Time: - lZ z-?Ara
Gauge Serial #: OSn Ct7 d9Pc/
District Required Info: r
Tester Certification #: 7Sa
Date Certification Expires: ri za 17
Test Results:
Backflow Prevention Device Test & Maintenance Report
-PASS ❑ FAIL
9/a03Vo3 12362
Water District/Authority: <all,M r Account: Contact Person:
Facility Name: Mf's Contact Phone:
Service Address: i a
Mailing Address: +r1�
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company NamefTitle: Contact Phone:
Mailing Address:
Make: f b<v Model: -2r 5' Size: '
Type: ❑ RPZ ❑ DC U PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: S, c torn aS' AL7 �5cv
O Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet.- ❑ Domestic ❑ Containment
�O vertical Up ❑ ❑ Fire ye Isolation
- New Installation ❑ Vertical Down ❑ ) Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal Z ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ CkR1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
C
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
w ' w
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV. RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
1-1 Air Inlet ❑ Air Inlet
Air Inlet
' o
Air Inlet
Air Inlet, PVB, SVB
❑ o et ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak )El Ti ht
sOV #1 )l Open Upon Arrival Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak
Tight
SOV
#2 . Open Upon Arrival - Open At Departure
Assembly Concerns:
at Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA IN ASSE
❑ Incorrect Use
Turnoff date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # , 7 B995
Person Notified: Ark Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
1 hereby certify that the isolefion/Shutolf Valves (SOV 51 and 80V 52) have been returned to the position in~ they "refound and that the last test was done according to
the procedure shown above required by the Water District/Authority shown above) and the We readings are true and accurate to the best of my ability.
(please print) AJs Backtlow (please print)
Testing Company: TestMg LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) i
Tester Name: AJ Simonson Tester Signature: 41Z Customer Signature:
Backflow testers who test or repair assemblies ond fire line must be registered with the Colorado Division of Fire Safety.