HomeMy WebLinkAbout432 BOW CREEK LN - SPECIAL INSPECTIONS - 3/14/2013CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION•EMERGENCYSERVICES ' Assembly Serial #: 034ZJ `
A 's B2G Testing LLC TestDate/Time:
tGauge
Serial #: o60Soo
89
"Your Cross -Connection Connection" District Required Info:
154027th Street, Greeley, CO 80631 Tester Certification #: -WIG D
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794 Date Certification Expires: /1�30-15.
Website: ajsbackflowunting.com E-mail: ajsbft@eanhlink.net
Assembly Test Results: X PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report /
13/3006 �1/
Im
Water District/Authority: -YeG
d Account:
Contact Person:
Facility Name:
Contact Phone:
Service Address: Q i� r
r rier Co//.t,
s n�s
a Mailing Address: ni Aloe
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
2 Company Name/Title:
Contact Phone:
1 Mailing Address:
Make: Eico
Model: 7/os Size: '✓4
Type: ❑ RPZ ❑ DC 3Z PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: 1-t
SJG v-R haKo?
IS ❑ Replacement Device
Orientation
Service Protection
previous device serial #
Inlet: Outlet:
❑ Domestic ❑ Containment'
Vertical Up ❑
❑ Fire Olsolation
❑ New Installation
❑ Vertical Down ❑
JH'Irrigation ❑ Containment by Isolation
❑ Stolen
❑ Horizontal ]i
/
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
55-
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑.Ck#2 ❑ RV
Ti htness Differential
Check Valve #1
❑ Leak
/
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
'XI Tight
r
❑ disc ❑ spring ❑ seat
❑ other -
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
'V. RPZ, DC
❑ Tight-
❑ disc ❑ spring ❑ seat
❑ other
❑Tight
Relief Valve
RV
C RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
0 RPZ
ElAir Inlet
ElAir Inlet
4, Air Inlet
Air Inlet
to Air inlet, PVB, SVB
'
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
❑ Leak OTi ht
SOV #1 ❑ Open Upon Arrival ®Open At De artu�reBackpressure
exists? ❑ YES ❑ NO
Shutoff Valve #2
❑Leak Tight
SOV #2 ❑ Open Upon Arrival r ❑ Open At Departure
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 1,2; B995
c Person Notified: A Contacted by:
Z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
1 hereby certify that the isolatiorvshuto# 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.
0 (please print) AJs Backf/ow (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 on• fire line must be registered with the Colorado Division of Fire Safety.