HomeMy WebLinkAbout427 TORONTO ST - SPECIAL INSPECTIONS - 8/23/2013CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION -EMERGENCY SERVICES
%3 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: ajsbackfiowtesting.com E-mail: ajsbft9eanhlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
Tester Certification #: 79,50
Date Certification Expires: i/. 3v-/s
Backflow Prevention Device Test & Maintenance Report
14733
Water District/Authority: iLCO Account: "Contact Person:
Facility Name: c n cor 0 ei Contact Phone:
Service Address: Q. tZr!`n 4o S�. F��4- /, //,,- -4
Mailing Address: 5a m e
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: �P�ro Model: 7& 5 Size: 4
Type: ❑ RPZ ❑ DC RP PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: o-.� kws;io
❑ Replacement Device Orientation _ Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
7' Vertical Up ❑ ❑ Fire 1011solation
New Installation ❑ Vertical Down El%Irrigation El Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
ElCkgt ❑ ck#2 ❑ RV
FCleaned:
k#1 ❑ ckttz ❑ RV
Re -test Results:
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
�7
❑ 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
Repaired: Cleaned:
Buffer
RPZ
'
`
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air Intel, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak E`J Ti ht
SOV #1 [Q O en U on Arrival ®70 en At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak J5 Tight
I SOV #2 Open Upon Arrival ROpen 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:
1 Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # /� B995
c Person Notified: n Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: s- /A- /?
I hereby certify that the isolation/ShutoB Valves (SOV #1 and SOV 412) 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/Authority shown above) and the test readings are true and accurate to the best of my ability.
Y (please print) AJs Backflow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Cu tomer Name: ---Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: /.' Customer Signature:
Backflow testers who test or repair assemblies .afire line must be registered with the Colorado Division of Fire Safety.