HomeMy WebLinkAboutFire Protection SystemAFFORDABLE. FIRE PROTECTION, INC
r'1ww. 914.e31.1t4.1
ra. CO 1 LA4 is 170-e14e04
..., 143914 Real
Test Report #:
Water Authority'
Assembly Serial #: OG1826
Test Date: 1-12.2015 Time.
Gauge Serial #- 099075
Account # ; 7294-2— -- ._ .
Tesler Certification #, 1865G
Date Certification Expires: 4-30-20-11----
Assembly Test Results Q Pass Initial ❑ Pass Final
Backflow Prevention Device Test & Maintenance Report
(please pant and submit completed copy within 10 days of the test)
❑Fail
S Facility Name
3 Service Address:
LDS Church
300 Stpprelle Dr
Contact Person
Contact Phone
❑i owner 0 Manager ❑ Centracior
Company Name/Title.
Mailing Address:
❑ Other
Contact Person
Contact Phone
Make Ames
Type URFz kj DC U Pva
Date Installed:1-2015
;tat
se
a
Replacement Device Orientation
1 lnlek
1 ❑ Vertical Up
0 Vertical town
❑ Horizontal
Prewous device serial
y�
L. New installation
❑ Stolen
lAftgyik
GheCA
RPZ OC PVB SVB
"Check Valve #2
RPZ DC
Relief Valve _
RV RPZ
Buffer
RPZ
Air Inlet
Air inlet PVB. SVB
Shutoff Valve #1
Shuto Valve iM2
Aaaambly Cont:ems. Teat
(only if applicable) Procedure: �-
❑ Incorrect Installation 0 ABPA
0 Incorrect Use ❑i ASSE
Model Colt 300 _
L..J Sve C Air Cap ---_..,-,._., AVB -.
Location on Property'
Service
Outlet. fl Domestic
❑ i Fre
❑ ❑ Irrigation
❑ ❑ Other
Size'
1 ,Other Device
Protection
❑ Coniauunem
Q Isolation
C Conlainmcnt by Isolation
Initial Test Results Repaired 1 Cleaned Re -test Result
s:
T hlneSB O+IVereralial Glut eks7 Rv Ctat C '[ i av I rprt<riesa�"Ditfererntal
Leak
Tight 3'$ disc son. seat _f� other
I i j l
Leak Ck#2
T9 ht 4'0 ,:RV�^-�•disc .1...11
i Il eft 11 1 seat 1 ,1 when
I.11..4 a1Fm u Seat
Airinlet�
_ Air inlet. " ..
— 1� riepered — aCetar!ee
l Aur Inlet
—
pelel _� Bam�ei °tiler.
leak Tiphi �Sdv i+topen upon anvil ! Open wan &ruesBx*w
prcere exlsts7 Erie; Na
,may Leek Tips T SOY +r2 I Open upah aaw
lval f Open en tlepyws
pure 1 Ca./
Comments
m Alarm Company/Fire Department Notified Fire suppression contractor certificahon # d6t3
Person Notified Contacted by JIM REMY
2 Turn of date Tum off time. Tum on date Tum on time -
c Test Kit Make BARTON
1—
Model
226C
Last Calibration Date
1/27/2014
eanby mal Mat Me aoanwrsrr®n Yir ee iSOY r r end sae ra haw been fawned b are nevem n whet they were 1E44,3d And That Me fast test was acne aopYprq ta the
propdue snowy, abo.a tethered by the Wale -D seernt etanty Sayan abate) we the test teee+gs ate bur ar d accurate la Me best a my Dobry
(Neese Pont) (please Arent)
Testing Company Affordable Fire Pork/ Phone. 970.858.8863 Customer Name Phone
(Please Pont)
Tester Name. Jim Remy Tester Signature,n".:'"`"" Customer Signature
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety
Assembly Serial #
Test Date/Time
Gauge Serial #
10 District Required Info
Teater:Certification #
Dale Certification .Expires:
5
-3.x"3.
Assembly Test Results Pass ❑Fail
Backflow Prevention Assembly Test & Maintenance Report est #:
(Please Rant)
�, Water District) Authority:
o Facility Name: (' wvtii
White:
Aiiiin 0 Account: �_ _ _ Contact Person:
O — �-€-S,rs CAEEl'LAS Contact Phone # :
3 Service Address: ?Oa S jpec.!-+-d-(e —
a Mailing Address:
Owner, Manager
o Company Name/ le:
Mailing Address:
Contrac or o Othe
kl ne..�
: Contact Person:
06.70
� �• Contact Phone # :..
.?3
f'gaa Or, f 14 4 S»l-ThL t ,4 �.- g 41e a
Make: Model: (907 Yin 101— Size: �r
Type: RPZ
Date I nstalled j-' 5—
DC • PVB
❑ SVB" 0 Air Gap
Property: Gt/y 'L 414y
AVB ❑Other
27/5 Location on
/Z v%4 e Z e iri-er
E (Only if Applicable - Include
N 0 Replacement Assembly
< ew installation(
Stolen
Previous Assembly
Previous Serial#)
Serial # %% A
Orientation Service Protection
Inlet: Outlet %omestic Containment
T Vertical Up 'i X ❑ Fire o Isolation
0 1 Vertical Down i s ❑ Irrigation Li Containment
❑ -, Horizontal -F t, o Other By Isolation
Line PSI: 62_0
Initial Test Results
Repaired:
ck#1 r Ck#2o RVo
Cleaned: Re -Test Results
Differential
Ck#1 o Ck#2o RVo Tightness l Differential
_Tightness
Check Valve #1 ❑ Leak -i•Ck#i o Leak
(Ck#1• RPZ, DC, PVB,SVB} -14 Tight pc.. I disco springo sesta other • i❑ Tight
Check Valve #2 ❑ Leak '
(Ck#2: RPZ, Dc) ).4 Tight ai 3
Ck#2 ❑ Leak i
disco spring❑ seato other: a Tight
3 Relief Valve
2 (RV: RPZ) a
Buffer .
i (RPZ) \
°a Air Inlet
co
(Air inlet: PVB,SVB)
_
PV ,
diaphram seato other.
o
Repaired: Cleaned.
Air Inlet a , Air Inleto
Airinlet
poppet o 'bonneto other `
V Shutoff Valve #1
o Leak Niz Tight
SOV #f Open Upon Arrival:o Open Upon Departure: o Backpressure Exists? Yes ❑ No 0
SOV#2 Open Upon Arrival o Open Upon Departure: o Cause:
Shutoff Valve #2
❑ Leak 'q Tight
Assembly Concerns:
(only if applicable)
Incorrect Installation? ❑
Incorrect Use ? 0
Test Procedure:
ABPA 0 ASSE ,
1013 _
Comments:
Turn off Date:1 /5 /).S. Turn On Date: ) / S i }S
Tum Off Time: : Tum On Time:
d Alarm Company/Fire Department Notified:
o Person Notified:
Contacted By: _ _ _ _ ___
z Turn Off Date/Time:
_
Tum On Date/Time:
R Test Gauge Make: 1- S! /11 Model: 3,� Last Calibration Date: _ / / 0/ Y
1 hereby certify that the Isolation i Shutoff Valves (SOV#1 and
procedure shown above, required by the Water
.. ..- _ -- - ---..�
(Piease'Priht) _ -
11 Testing Company:. Phone
SOV #2) have been returned to the position in which they were found and that the test was done according to the
District/ Authority shown above;,and the tesrreadings are true and accurate to the best or my ability.
-
.. -.. _ - -
� 1(Please'Prinq
#- O }j (Customer Name:Phone #
CU
Tester Name: t tJ #V , eeC-f
(Please Print)
(Customer) i
.-
Signature: -.ALL,ALL-
(Tester) r
Signature: j..)
White: CMD / Yellow: Certified Technician / Pink: Customer