HomeMy WebLinkAbout607 STONEY BROOK RD - SPECIAL INSPECTIONS - 5/8/2012CONSULTING -TESTING - SALES- REPAIRS
INSTALLATION- EMERGENCY SERVICES
Ag's Bac �°x' 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: ajsback0owtesting.com E-mail: ajsbft@eathlink.net
Assembly Serial #: fi (07&MV
Test Date/Time: �-- 5-)Z /4) 3&Am
Gauge Serial #: 0 t e:: S,?
District Required Info:
Tester Certification #: 17r5F'5-0
Date Certification Expires: //-3y—Iz
Assembly Test
Backflow Prevention Device Test & Maintenance Report
11006
Water District/Authority: 4 r/ /G i i Account: Contact Person:
Facility Name: %T f,&W&5 Contact Phone:
Service Address: a67 S4kN; e v 9evo,t -lr it-1-
Mailing Address: _51&/ Itt.
❑ Owner ❑ Manager El Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
�
Mailing Address:
Make: FP6' w Model: 7K5 Size: 19e
nu
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: G�z%PGc05r"
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet ❑ Domestic ❑ Containment
1 Vertical Up ❑ ❑ Fire � Isolation
New Installation ❑ Vertical Down ❑ >C] Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ,Z ❑ Other:
i
Line PSI:
Initial Test Results:
Repaired: Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Tightness
Differential
Tightness Differential
h�
Check Valve #1
❑ Leak
�1
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
I
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
�d
v
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑Leak
Ti ht
SOV #1 open Upon Arrival 19 Open At Departure Backpressure exists? ❑ YES ❑ NO
SOV #2 open Upon Arrival Open At Departure Cause
Shutoff Valve #2
❑ Leak Ti ht
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
" f
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
'
Alarm Company/Fire Department Notified: Fire suppression contractor certification # /Z B995
o
Person Notified: /% Contacted by:
m;
Turn off date/time: Turn on date/time:
-
Test Kit Make: Mid -West Model: 845 Last Calibration Date: ::5�— /�_ //
I hereby certify that the isolation/Shutoff Valves (SOV #1 and SOV #2) have been returned to the position in which they were lbund and that the last test was done according to
the procedure shown above required by the Water DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
Testing Company: Tesft LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: 4L I Customer Signature:
Backflow testers who test or repair assemblies o afire line must be registered with the Colorado Division of Fire Safety.