HomeMy WebLinkAbout456 SAN JUAN DR - SPECIAL INSPECTIONS - 10/17/2012CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
A,g's Back Tolw fisting LLC
"Your Cress -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbft@eanhlink.net
Assembly Serial #:
Test DateiI ime:
Gauge Serial #:
District Required Info:
Tester Certification #: I,? -TO
Date Certification Expires: //-30 /L
Assembly Test Results: )] PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
12430
+M Water District/Authority:F-I- eo)/ U .26or /_ Account: Contact Person:
Facility Name: o Contact Phone:
Service Address: 4sro Scn can Or +t* ZA'k- to 00!�.7S
Mailing Address: SG me
f' „ ❑Owner ❑Manager ❑Contractor ❑Other Contact Person:
1
2 Company Name/Title: Contact Phone:
f Mailing Address:
Make: Model: 7G 5 Size: 314
fM1; Type: ❑ RPZ ❑ DC `n PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: c?-(- hOVSP
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
)7 Vertical Up ❑ ❑ Fire 32 Isolation
)Z New Installation ❑ Vertical Down ❑ 9 Irrigation El Containment by Isolation
❑ Stolen ❑ Horizontal lP ❑Other:
` ,
Line PSI:
Initial Test Results:
Repaired:
❑ ckat ❑ ckn2 ❑ RV
Cleaned:
❑ ck#t ❑ ckaz ❑ RV
Re test Results:
Ti htness Differential
Ti htness Differential
Check Valve #1
Y
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ 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
Repaired:
Cleaned:
s Buffer
EstD RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Air Inlet
Air Inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
++. Shutoff Valve #1
1 ❑Leak >n Ti ht
SOV #1 %❑ Open Upon Arrival JE Open At Departure
Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
1 ❑Leak Tight
SOV #2 Cl Open Upon Arrival ❑ Open At Departure
Cause
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 # 1r B995
Person Notified: A)A Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: 6L-A k2L
j I hereby certify that the isolationlShutolf 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 DistriebAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backf/OW (please print)
ATesting Company: Testing LLC Phone: 970-352-3090 Cu toL Phone:
(please print))
�etName:
Tester Name: AJ Simonson Tester Signature: �1 Customer Signature:
Backflow testers who test or repair assemblies oct a fire line must be registered with the Colorado Division of Fire Safety.