HomeMy WebLinkAbout450 BOW CREEK LN - SPECIAL INSPECTIONS - 12/12/2012b / a 0\oP-2;D
CONSULTING -TESTING -SALES- REPAIRS
INSTALLATION -EMERGENCY SERVICES
%3's B"Tow r_T_e'sdnq LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackilowtesting.com E-mail: ajsbf1'9eWhIink.nei
Assembly Serial #: 114-7069621
Test Date/Time: a-12-12 447AIN
Gauge Serial #: e---) g rjgr_,o
District Required Info:
Tester Certification #: 7150
Date Certification Expires: 1130-17
Assemblv Test Results: )d PASS OFAIL
Backf low Prevention Device Test & Maintenance Report
Water District/Authority: Account: Contact Person:
Facility Name: .r Contact Phone:
Service Address: loail,2 er-e e L' -V- 6/4 t.:s e-0 G304.7,c;-
Mailing Address: -W
1E
��j 0 Owner 0 Manager 0 Contractor 0 Other Contact Person:
Te Company Name/Title: Contact Phone:
Mailing Address:
Make: 7/ bees Model:
e� .4;5, Size:
Type: 0 RPZ 0 DC PVB 0 SVB C3 Air Gap 0 AVB 0 Other Device
Date Installed: Location on Property: All f- elnn Pe- 4&I-C hoc f 50f
0 Replacement Device Orientation Service Protection
-1 previous device serial If Inlet: Outlet., 0 Domestic 13 Containment
'1 Vertical Up 0 13 Fire 'Isolation
0 Vertical Down 0 irrigation El Containment by Isolation
New Installation ❑
.0
11 Stolen El Horizontal El Other:
Line PSI:
Initial Test Results:
Repaired:
0 Ck#1 0 Ck#2 [I RV
Cleaned:
0 Ck#1 0 Ck#2 El RV
Re -test Results:
GO
Tightness Differential
Tightness Differential
Check Valve #1
ED Leak
Ck#1
11 Leak
RPZ, DC, PVB, SVB
Tight
El disc 0 spring 11 seat El other
C3 Tig I
0 Tight
Check Valve #2
E) Leak
Ck#2
0 Leak
RPZ, DC
El Tight
11 disc 0 spring C3 seat 0 other
r_1 '�
11 Tight
Relief Valve
RV
RV, RPZ
El Diaphragm 0 seat 0 other
-4 BufferRepaired:
RPZ
El Air Inlet 0 Air Inlet
I.
Air Inlet
Air Inlet
,lip Air Inlet, PVB, SVB
I-
alp,❑0
111 poppet bonnet 0 other
Ls —
Shutoff Valve #1
1 103 Leak Tight
SOV #1 El Open Upon Arrival Open At Departure
Backipressure exists? 11 YES C3 NO
Cause
Shutoff Valve #2
1 0 L ak )M Tiqht
SOV #2 El Open Upon Arrival 0 Open At De arture
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
0 Incorrect Installation
El ABPA IM ASSE
11 Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: 0 Fire suppression contractor certification # 12 B995
0 Person Notified: 44 Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 — Last Calibration Date: Aiaao_14_7
I hereby certify that the isolation/Shutoff 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.
(please print) AJs Backfidw (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) (I
Simonson
Tester Name: AJ Tester Signature: elz�l — Customer Signature:
Backflow testers who test or repair assemblieon a fire line must be registered with the Colorado Division of Fire Safety.
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