HomeMy WebLinkAbout451 HOUGHTON CT - SPECIAL INSPECTIONS - 8/23/2013CONSULTING •TESTING -SALES -REPAIRS
INSTALLATION - EMERGENCY SERVICES
(BWS B"c Tow fisting LLC
our Cross -Connection Connection"
1540 27th Stmet, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbfv9earthlink.net
Assembly Serial #:
Test Date/Time:
74 S
s:/Z PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report j1�J
Gauge Serial #: n�nSm:44
District Required Info:
Tester Certification #:
Date Certification Expires:
14750
., Water District/Authority: r/ C o Account:
Contact Person:
Facility Name: c mco'e t-k'me-
Contact Phone:
u' Service Address: 451 Jjrny1 l440. C-4- (7+ �nl/,hs �n
Ap-5-24
Mailing Address: Sc rn to
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
Mailing Address:
Make: rr P4va Model:
Size: }/4
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: U),
:rr/P 6-1�Ao>✓SP
t
❑ Replacement Device Orientation
Service Protection
previous device serial # Inlet: Outlet:
❑ Domestic ❑ Containment
19? Vertical Up ❑
❑ Fire '&a'fsolation
New Installation ❑ Vertical Down ❑
Irrigation ❑ Containment by Isolation
a ❑ Stolen ❑ Horizontal 1-0
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Tightness Differential
Check Valve #1
❑ Leak
��
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
J2 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
Buffer
Repaired:
Cleaned:
RPZ
❑ Air inlet
❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
I ❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
❑ Leak Tight
I SOV #1 i) Open Upon Arrival Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak Tight
SOV #2F0 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 # f3 B995
Person Notified: 4Aa
Contacted by:
Turn off date/time:
Turn on date/time:
eT Test Kit Make: Mid -West Model: 845
Last Calibration Date: z '-/A-/T
I hereby certify that the isolatiorvShuto%Valves (SOV 61 and SOV #2) have been returned to the position in which they were found and that the last test was done according to
---I 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.
(please print) AJs Backflow
(please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
!) 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.
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