HomeMy WebLinkAbout427 STONEY BROOK RD - SPECIAL INSPECTIONS - 3/28/2013i
CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
_qj's Bac �O'1W Estt11g aC
"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(searthlink.net
Assembly Serial #: # 71 Soo4
Test DatelTime: 4-Z_ R l i it ;oaAA
Gauge Serial #: oA;nt;roA4
District Required Info:
Tester Certification #: -24 o
Date Certification Expires: it-3o-lf
Backflow Prevention Device Test & Maintenance Report
Water District/Authority r 4 161 rhs LQ?6.c/ Account: Contact Person:
3 Facility Name: Contact Phone:
4Z
Service Address: 9 L l-,nok
a Mailing Address: Sa on o
VI ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name/Title: Contact Phone:
c)
Mailing Address:
Make: a Model: 764 Size: -�?IA
Type: ❑ RPZ ❑ DC] PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
-- �ajs'p
Date Installed: Location on Property: St 62ro0l%l
a
E ❑ Replacement Device Orientation Service Protection
0 previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q f 0' Vertical Up ❑ ❑ Fire >Q Isolation
New Installation ❑ Vertical Down ❑ 0 Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
(ctc_
Tightness Differential
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
o7�
El disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
O Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired: ____T!Cleaned:
Buffer
CO RPZ
El Air Inlet ❑ Air Inlet
etj Air Inlet
l 8
Air Inlet
CMAir inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
❑ Leak �E Tight
SOV #1 KI Open Upon Arrival JE Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak 0 Tight
SOV #2 ❑ open upon Arrival ❑ Open At De arture
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 #/? B995
c Person Notified: 1 1A Contacted by:
z Turn off date/time: Turn on date/time:
Ng Test Kit Make: Mid -West Model: 845 Last Calibration Date: .So20-,17
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 DistrictlAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
y Testing Company: Testing LLC Phone: 970=352-3090 Customer Name: Phone:
F' (please print))
AJ Simonson
Tester Name: Tester Signature: �rr,G Customer Signature:
Backflow testers who test or repair assemblies pda fire line must be registered with the Colorado Division of Fire Safety.