HomeMy WebLinkAbout415 HOUGHTON CT - SPECIAL INSPECTIONS - 8/23/2013CONSULTING • TESTING -SOLES -REPAIRS
INSTALLATION -EMERGENCY SERVICES
A,"T's Bac Tow fisting LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office (Y70-352-3090 Celt 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbft(1Pearthlink.net
Assembly Serial #: N -7D4 S5'S
Test Date/Time: e-23-13 )v;3&Aoi
Gauge Serial #:y Solon fi"1
District Required Info:
Tester Certification #: -71 5 0
Date Certification Expires: 1130-1 5-
Assembly Test Results: A PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
05
14747
C Water District/Authority: Account:
Contact Person:
Facility Name: £'n e or e /-vrl eos
Contact Phone:
Service Address: IS/.4cixt,C4- tC6/0h
Mailing Address: 5
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
T Company Name/Title:
Contact Phone:
a Mailing Address:
Make: Fa GrC) Model:
7,-,5 Size: 314
Type: ❑ RPZ ❑ DC ?9 PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: A)/
5-,'de a-(' AovSP
❑ Replacement Device Orientation
Service Protection
previous device serial # Inlet: Outlet:
❑ Domestic ❑ Containment
Vertical Up ❑
❑ Fire Isolation
tp�I New Installation El Vertical Down ❑
RIrrigation ❑ Containment by Isolation
' L11 Stolen ❑ Horizontal C`l
T
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#t ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#t ❑ Ck#2 ❑ RV
Re -test Results:
O
Tightness Differential
Tightness Differential
Check Valve #1
'
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
e�;rI
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
av RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Repaired:
Cleaned:
Buffer
t� RPZ
❑ Air Inlet
❑ Air Inlet
atl Air Inlet
// a
Air Inlet
Air inlet, PVB, SVB
C
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
1 ❑ Leak Nil Ti ht
SOV #1 Open Upon Arrival JO Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak Ti ht
I SOV #2 Open Upon Arrival Open At De arture
Assembly Concerns:
T st 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 # /3 B995
Person Notified: 4A
Contacted by:
Turn off date/time:
Turn on date/time:
Test Kit Make: Mid -West Model: 845
Last Calibration Date: S- /FR-/ 3
I hereby certify that the isolation/Shuto#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 BaCkf/Ow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t-
(please print)) r
Tester Name: AJ Simonson Tester Signature:
Customer Signature:
Backflow testers who test or repair assemblies on a i 'line must be registered with the Colorado Division of Fire Safety.