HomeMy WebLinkAbout439 HOUGHTON CT - SPECIAL INSPECTIONS - 5/20/2014. CONSULTING• TESTING%SUES -REPAIRS
INSTALLATION- EMERGENCYSERMES -
?{,�'s BAGI JWW '1 estina 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 #:
1 7
Test Date/Time:
,PA
Gauge Serial #:
'DZo0707T
District Required Info:
Tester Certification #:
7950
Date Certification Expires:
/1-33-15
Assembly Test Results: �Rl PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report t
16134
Water District/Authority: :5LCo Account: Contact Person:
Facility Name: a IC Contact Phone:
Service Address: d3q g4x. f.-hr t^-i !F7+
Mailing Address: _!5c-m p
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
- Mailing Address:
arMake: {'`"�eh[O `- Model: �� Size: 3t
k
Type: ❑ IRPZ d7 DC )O PVB , , ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
t s �� 04- �� se
Installed: � Location on Property: �.
❑ Replacement Device , -s Orientation Service. Protection
previous device'senal # Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑Fire Isolation
New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
❑ Stolen _ ❑ Horizontal �p ❑ Other:
Line PSI:
Initial Test Results:
Repaired:" --T
❑ Ck#1 ❑ Ck#2 ❑ Rv
Cleaned:
❑ ck#t ❑ ck#2 El
Re test Results:
d
Tightness Differential
Ti htness Differential
Check Valve #1
❑ Leak
t
Ck#1
❑ Leak
RPZ, DC,'PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
10 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
1006-r Air Inlet
t
Air Inlet
lOf Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
( Shutoff Valve #1
(
❑ Leak 2PTight
SOV #1 Open Upon Arrival 2 Open At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑Leak Ti ht
SOV #2J2 Open Upon Arrival 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 B995
Person Notified: 44a Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: -7-16-14
1 hereby certify that the isolationvShutoff 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/Authority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backillow (please print)
fm Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
F- (please print)) a
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on a fir , ine must be registered with the Colorado Division of Fire Safety.
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