HomeMy WebLinkAbout946 SNOWY PLAIN RD - SPECIAL INSPECTIONS - 2/25/2011T-•
FROM :COMPONENT SYSTEMS FOR TURF FAX NO. :482 8832 Feb. 25 2011 10:22AM P1
%a Assembly Serial #:::.
Test Datelrime: 6 Qt
COMPONENT SYSTEMS LLC Gauge Serial #: 9 1s s
Backflow Testing Services District Required Info: Permit # 81005412
Tester •Certification #: ASSE 6403
970-472-9773 p C •
ate ertification Expries. 3/10/2012
Assembly Test Results: PASS ❑ FAIL
RETAIN A COPY OF THIS REPORT FOR THREE YEARS
Facility Name:
Service Address: 946 Snotiv}r Plain Rd.
Mailing Address:
Contact Phone:
11-Malling
Owner U Marwger U Contractor U other Contact Person: Mike SteinmetzCompany Name/Title: �' l�i¢O �r�% G R a le- Contact Phone: 720-301-1333 Address: 2861 W. 420th Ave. #240, Westminster 80236
Type: ❑ RPZ
❑ DC APVB ❑ SW ❑ Air Gap
❑ Ave ❑ Other Device
Date Installed: Location on Property: East side of house
❑ Replacement Device
Orientation
Service
Protection
::previous device serial #
Inlet: Outlet:
❑Domestic
❑ Containment
•�"='
vertical up E)
❑ Fire
El Isolation
[� New Installation
PERMIT #: ❑'verti�l ❑
❑ Irrigabon
❑ Containment by Isolation
❑ Stolenj1
�,C y% ❑ Horizontal ❑
❑ per_
a t_i a PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ Rv
Re -test Results
s�a
Tightness Differential
TI htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
L?C. ma's, SVi3
Tight
aG
❑ disc ❑ spring ❑ seat ❑ other:
❑ Tot
Check Valve #2
❑ Leak
Ck#2
❑ leak
k z, r)c .
[ ] Tight
❑ a9c. ❑ spring ❑ seat ❑ other--
❑ Tight
Relief Valve
RV. f4Pz
RV
❑ Diaphragm ❑ seat ❑ other:
Repaired:
Cleaned:
Buffer
rpZ.
❑ Air Inlet
❑Arc Inlet
Air Inlet
Air Inlet
'A;: i ,!.:i. Pl•'�. Si'r�
❑ poppet ❑ bonnet ❑ other:
Shutoff Valve #1
=k Wight
SOV #1: Lj Open Upon ArrivalArrivalM Open At Departure
Backpressure
Cause
exists? LJ Yt3 LJ NO
Shutoff Valve #2
Leak
ITight
SOV 92: Lj Open upon Arrival LJ Open At arture
`•Assembly Concerns:
R r�i
Test Procedure.
Comments:
C )/� �d J� sJ"✓ lJM 0 7�� s1�i rG[
ABPA ❑ ASSE
�etee'❑ Incorrect Installation
�-tlt�❑ Incorrect Use
Cs.r1 d d /Y�; d /'t .Q d , h S. e a1
0 Turn off date:
Turn on date:
,Turn off time:
ITurn
on time:
tAlarm.Company/Fire Department Notified Fire Suppression contractor certification #
91007
Person Notified:
_
Contacted by:
Turn off date/time: Turn on date/time:
�r..
--Test Kit Make:
Midwest Model: 845-5 Last Calibration Date:.
i
t hereby ce" that the lsoiation/ShutoN Valves (SOV #f and SOV #2) have been miumed to the posihpn in whlch they were found and that the Yost test rms One according to the
procedure shown above required by the Water D/sMVAuthority shown zoow)
(please print)
(Meese print)
Testing Company:
Component Sys Phone 472-9773 Cu_sigmt Name:
Phone
(please print)
_ 9F.
-„,�Tester.Name: Charlotte Harms rester Signature: Customer Signature:
- water supplier- Yellow - Testeir Ping - owiler