HomeMy WebLinkAbout444 HOUGHTON CT - SPECIAL INSPECTIONS - 8/23/2013CONSULTING •TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
%3 s Bac �ow 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: ajsbft@earthlink.net
Assembly Serial #: Zc4 fkq
Test Date/Time:-I cif. GAAsn
Gauge Serial #: ham,-,5on99
District Required Info:
Tester Certification #: 795-n
Date Certification Expires: i/-3cris-
Assembly Test Results:�.Z PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
14753
Water District/Authority: %r-L e- y Account: Contact Person:
Facility Name: Contact Phone:
Service Address: A d /-looy h 4,. r -I -r4 thi,
Mailing Address: s4cr)e
M>❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
- Mailing Address:
Make- Model: 5 Size: 3�4
Type: ❑ RPZ ❑ DC )l PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
g� Date Installed: Location on Property:
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire .Pletsolation
VNew Installation ❑ Vertical Down ❑ irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
"
Tightness Differential
❑ Ck#t ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
G Buffer
Repaired: leaned:
RPZ
❑Air Inlet Inlet
7oAir
Airinlet
Air Inlet
Air inlet, PVB, SVB
I❑
'
poppet ❑ bonnet ❑ other
Shutoff Valve #1
1 ❑Leak Ti ht
I SOV #1 10 Open Upon Arrival Open At De arture Backpressure exists? ❑YES ❑ NO
SOV #2 Open Upon Arrival Li Open At De arture Cause
ER,Shutoff Valve #2
❑ Leak Tight
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 # (3 8995
1101 Person Notified: Contacted by:
, Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date;
I hereby certify that the isolation/Shutoff Valves (SOV # 1 and SOV #2) have been returned to the position in which they were round 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.
ja (please print) AJs Backfiow (please print)
0 Testing Company: Testing LLC Phone: 97"52-3090 Cust mer Name: Phone:
~I (please print))
j Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies o, a fire line must be registered with the Colorado Division of Fire Safety.