HomeMy WebLinkAbout415 NOQUET CT - SPECIAL INSPECTIONS - 8/23/2013CONSULTING • TESTING • SOLES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
017'S Bac Tow '12Sting f—LC
'Tour cross -connection connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackilowtvaing.com E-mail: ajsbfigearthlink.nel
Assembly Serial #: N -25olf 2? 3
Test Date/Time: t3 73- i i 1%(51AM
Gauge Serial #:
District Required Info:
Tester Certification #: 7qS/-)
Date Certification Expires:
Backf low Prevention Device Test & Maintenance Report
Water District/Authority: zez co Account: Contact Person:
i:"' Facility Name: Contact Phone:
Service Address: 4 1-; A)oq%.pa- c-4 t•' ramAo5',04
Mailing Address: M�
ElOwner ❑ Manager ❑ Contractor ❑ Other Contact Person:
I Company NamelTitle: Contact Phone:
IS Mailing Address:
Make: re faro Model: % 5 Size: -3/d
Type: ❑ RPZ ❑ DC YPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property:
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
X Vertical Up ❑ ❑ Fire 9Isolation
)7 New Installation ❑ Vertical Down ❑ IR''Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#t ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
5
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
o7, v
❑ 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
r
❑ poppet ❑ bonnet ❑ other
A Shutoff Valve #1
1 ❑Leak 21 Tight
I SOV #1 ' O en Upon Arrival ®'Open At Departure
Backpressure exists? ❑ YES ❑ NO
ttm Shutoff Valve #2
1 ❑ Leak A Tight
I SOV #2R Open Upon Arrival f D Open At Departure
Cause
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 # 1-3 B995
Person Notified: 44A Contacted by:
2 Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West— Model: 845 Last Calibration Date:
1 hereby certify that the isolation/Shutoff 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 District/Authodty shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backfiow (please print)
y 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 on -Ejire fine must be registered with the Colorado Division of Fire Safety.