HomeMy WebLinkAbout4809 PRAIRIE VISTA DR - SPECIAL INSPECTIONS - 5/5/2015-4o+0z-7.
Test Date/Time: 5/5/2015 10:1 C
Guage Serial #: 13815
PHIL GREEN CONSTRUCTION District Required Info:
Tester Certification #: 17233
Date Certification Expries: 5/31/2015
Assembly Test Results: 0 PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
(please print and submit completed copy within 10 days of the test)
..; Water District /Authority:
FCLWD Account:
Contact Person:
Facility Name:
Contact Phone:
0i Service Address:
4809 PRAIRIE VISTA DRIVE FT COLLINS, CO 80526
Q Mailing Address:
❑ Owner ❑ Manager ❑� Contractor ❑ Other
Contact Person: MITCH GREENO
g; Company Name/Title:
PHIL GREEN CONSTRUCTION
Contact Phone: 420-9083
O Mailing Address:
1420 BLUE SPRUCE DRIVE FT COLLINS, CO 80524
i Make:
APOLLO Model:
P B4A Size: 3/4"
Type: ❑ RPz
❑ DC Ej PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
>; Date Installed:
5/4/2015 Location on Property:
EAST SIDE OF HOUSE
M
E, ❑ Replacement Device
Orientation
Service Protection
d device serial #
N, f previous
Inlet. Outlet:
❑ Domestic Containment
Q
Q Vertical Up ❑
❑ Fire ❑� Isolation
Q New Installation
❑ Vertical Down ❑
Q Irrigation
Containment by Isolation
' Stolen
! ❑
❑ Horizontal R]
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#I ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#I ❑ Ck#2 ❑ RV
Re -test Results
85#
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
0 Tight
1.2
❑ disc ❑ spring ❑ seat ❑ other:
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
a)i RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other:
❑ Tight
c, Relief Valve
RV
C. RV, RPZ
❑ Diaphragm ❑ seat ❑ other:
c;, Buffer
Repaired:
Cleaned:
io : RPZ
❑ Air Inlet
❑ Air Inlet
g I Air Inlet
Air Inlet
Air inlet, PVB, SVB
2.6
❑ Poppet ❑ bonnet ❑ other:
Shutoff Valve #1
1 Lj Leak Ll Tight
I SO #1: Lj Open Upon Arrival Lj Open At Departure
Backpressure
Cause
exists? Lj YES NO
y0i Shutoff Valve #2
✓ Leak Tight
SOV #2: Open Uponrival Open At ArDeparture
Assembly Concerns:
Test Procedure:
Comments:
(oily if applicable)
❑ Incorrect Installation
❑ ABPA ❑✓ ASSE
❑ Incorrect Use
i Turn off date:
Turn off date:
Turn off time:
Turn off time:
Alarm Company/Fire Department Notified:
(D;
=! Person Notified: Contacted by:
0 Turn off date/time: Turn on date/time:
Y;Test Kit Make: Watts Model: TK99E Last Calibration Date:
1/17/2015
I hereby certify that the isolation/Shutoff Valves (SOV #1 and SO V #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.
y (please print) (please print)
m Testing Company: Farber Lawn SVC Phone 490-2560 Customer Name: PHIL GREEN CONSTRUCTION Phone 420-9083
F- (please print)
Tester Name: Mark Farber Tester Signature: Customer Signature:
Backfiow testers who test or repair assemblies on a tire line must be registered with e Colorado ivision of Fire batety.