HomeMy WebLinkAbout421 SAN JUAN DR - SPECIAL INSPECTIONS - 10/12/2012CONSULTING - TESTING - SALES - REPAIRS
- INSTALLATION- EMERGE
,NC
CYYSERVICES
91g's B6i*OW -1 esting LCC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@eanhlink.net
Assembly Serial #:
970ba90
TestDate/Time:
ia-/.x-IZ 1/:07at�r
Gauge Serial #:
y�i�5oo89
District Required Info:
Tester Certification #:
79.,:�n
Date Certification Expires:
Jl 3o-/a-
Assembly Test Results: JE PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
12435
Water District/Authority: +Co1/(m lit Account: Contact Person:
�• Facility Name: �or✓r-tu- 1,6rneeP5 Contact Phone:
Service Address: 49 1 nJ Jc� /1 r)r F:4 %n//✓Y S l� 4()T�?�
Qi Mailing Address: 75LMe
V(❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name/Title: Contact Phone:
�(
Mailing Address:
Make: Model: -,Z,S Size:
Type: ❑ RPZ ❑ DC /9 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: Alt S,'c+p &47 �iyds2�
E ❑ Replacement Device Orientation Service Protection
0, previous device serial At Inlet: Outlet. ❑ Domestic ❑ Containment
a' 'AD Vertical Up ❑ ❑ Fire XJ Isolation
New Installation ❑ Vertical Down ❑ .40Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
❑ Ck#1 ❑ Ck#2 ❑ RV
: Ck#1 ElCk#2 El RV
�d
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other ,-moue debr? 5
Tight
/r
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
a Relief Valve
RV
0 RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
op, Air Inlet
O) Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
❑ Leak Ti ht
SOV #1 ❑ Open Upon ArrivalAn Open At Departure Backpressure exists? El YES ❑ NO
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture Cause
Shutoff Valve #2
❑ Leak Tight
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:
uAlarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # /T B995
e Person Notified: AA 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 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.
ly (please print) AJs Back iow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
f (please print))
�� Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies oyi a fire line must be registered with the Colorado Division of Fire Safety.