HomeMy WebLinkAbout508 BANNOCK ST - SPECIAL INSPECTIONS - 8/11/2014CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
. +y
�AJ's Bac flow Testing LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtes1in8.com E-mail: ajsbftCnearthlink.net
Assembly Serial #:
H 8Z SZq'-t
Test Date/Time:
8• 11 • I q I I: Lis
Gauge Serial #:
51 S 33Z
District Required Info:
Tester Certification #:
10 1 E� O
Date Certification Expires:
10 • Zo ?ol N
Accpmhly Tpct Rpai dtc• Fri PARA F-1 FAII
Backf low Prevention Device Test & Maintenance Report
17355
c Water District/Authority: F I C o
Account:
Contact Person:
c Facility Name: T kiC OIz
ice: w)� S
Contact Pone:
Service Address: nQ. 13A nl Ai CC K -ST.
FL • (L_ )11; kf S CC, BLS2 `i
a Mailing Address:
rJ ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
0
Mailing Address:
Make: F F ? i (l
Model:
S Size:
3L/ tirL 1-1
Type: ❑ RPZ ❑ DC ❑(PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: kt
orkh SInG t— X�1 S, or
k(A
M
E ❑ Replacement Device
Orientation
Service
Protection
w previous device serial #
Inlet: Outlet.
❑ Domestic
❑ Containment
Q' 1
❑ Vertical Up ❑
❑ Fire
❑ Isolation
E37New Installation
❑ Vertical Down ❑
((Irrigation
❑ Containment by Isolation
/❑ Stolen
❑ Horizontal ❑
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
Tightness Differential
So
❑ Ck#1 ElCk#2 El RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
(
I
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
ZTight
• `„)/
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
u RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
R Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
Repaired:
❑ other
Cleaned:
c Buffer
RPZ
❑ Air Inlet
Air Inlet
❑ Air Inlet
ad Air Inlet
C Air inlet, PVB, SVB
l�1
I 1
❑ poppet ❑ bonnet
❑ other
n Shutoff Valve #1
1 ❑ Leak
❑ Tight
SOV #1 ❑ Open Upon Arrival ❑ Open At De arture Backpressure
SOV #2 ❑ Open Upon Arrival ❑ O en At De arture Cause
exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak �Ti ht
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA 19 ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
0 Alarm Company/Fire Department Notified: ElFire suppression contractor certification # B995
c Person Notified: Contacted by:
z Turn off date/time: Turn on date/time:
yL Test Kit Make: J14id-West S
a M Model: -845— 9S Last Calibration Date: I. 11I I LI
• I 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 Distdct/Aulhodty shown above) and the test readings are true and accurate to the best of my ability.
a) (please print) AJs Backf/ow (please print)
y Testing Company: Testin-q LLC Phone: 970-352-3090 Customer Name: Phone:
E (please print)) SL t} M"1<2 I S
Tester Name:—AJ-Simonsen- Tester Signature: stomer Signature:
Backflow testers who test or repair assemblies on afire line must be registered with the Colorado Division of Fire Safety.