HomeMy WebLinkAbout438 HOUGHTON CT - SPECIAL INSPECTIONS - 8/23/2013CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION• EMERGENCY SERVICES
rArl's Bac Tow fisting LLC
"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: ajsbftOearthlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
r •�
Tester Certification #: 745�
Date Certification Expires:
Assembly Test Results:
Backf low Prevention Device Test & Maintenance Report
$`50�b
14754
Water District/Authority: /_ C a Account: Contact Person:
Facility Name: f..e nrP J._ „as Contact Phone:
Service Address: —Aa;-1 R kic, a A 4h ( S /
Mailing Address: �� ,n e
gTMe
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
cis, Make: � %� a Model: %r s Size: 3 4
❑ RPZ ❑ DC XPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
kType:
Date Installed: Location on Property: SS dPd Ao,)5e
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Lll Vertical Up ❑ ❑ Fire +Isolation
New Installation ❑ Vertical Down ❑ Wirrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re test Results:
Tightness Differential
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#i
❑ Leak
RPZ, DC, PVB, SVB
J21 Tight
'2'
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
=9 Check Valve #2
'Cl Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
' RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, Svs
C
cvt a
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak Tight
SOV #1 �E Open Upon Arrival 5 Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
-Assembly
❑ Leak JTCF Tight
SOV #2 ,E Open Upon Arrival Open At De arture
PI Concerns:'rest
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 # i3 B995
Person Notified: ?ig Contacted by:
2 Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: ; — 3
I herebycar* that the isolationlShutoNValves SOV #1 and SOV #2 have been returned to the fy ( ) position in which they were found and that the last test was done according to
the procedure shown above required by the Water DistricVAuthonly shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs BacMIOW (please print)
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 o -fire line must be registered with the Colorado Division of Fire Safety.