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7w$^i'_�.���m,qA�,-'Z AACRA Backnow Testing and Repair. Inc. <br />F.w`WA (360) 668.1117 <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />WATER PURVEYOR <br />Everett <br />ACCOUNT <br />ASSEMBLY ID/FILE #UTILITY DEVICE # Meter <br />NAME. OF PREN11SE 2631 Walnut St. <br />SERVICE ADDRESS 2631 Walnut St. <br />CONTACT P <br />Commercial v Residential _ I <br />Everett 711, 98201 <br />PHONE <br />LOCATION OF ASSEMBLY Back Room on_Rt. Wall just before entering freezer <br />DOWNSTREAM PROCESS Carbonation Dispenser DCVA ❑ RPBA sii PY'B.A ❑ OTHER <br />NEW INSTALL ❑i EXISTING ❑ REPLACEMENT REMOVED n OLDSER.# <br />APPROVED ASSEMBLY? YES ©NO❑ PROPER INSTALLATION? YES ;] NO ❑ <br />NUAKF.OFASSF.MIILNConhraco/Apollo MODEL RPLF4A SFRIALNo. 651914 SIZE •5 <br />DCVAIRPBA <br />DCVA/RPHA <br />RPBA <br />PVBA/SVGA <br />INITIAL <br />AIR INLET <br />CHECK VALVE NO.1 <br />CHECK %ALN E \0.2 <br />TEST <br />OPENEDAT" 3.0 rSID <br />CLOSED TIGHT '� <br />CLOSED"IIGH-I" J <br />OPENED AT PSID <br />PASSED <br />LEAKED <br />LEAKED ❑ <br />#1 CHECK 8.0 PSID <br />I111) NOT OPEN -- <br />FAILED ❑ <br />PSID <br />PSID <br />AIRGAPOK? YCS <br />- <br />CLEAN REPLACE PART <br />CLEAN REPLACE PART <br />CLEAN REPLACE PART <br />CH FA K \'AIAI- <br />NEW <br />❑ ❑ <br />❑ ❑ <br />_❑ <br />I HL1.DAI _ PSLD <br />PARTS <br />❑ ❑ <br />❑ G <br />L f1 <br />LEAKED [ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />AND <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />REPAIRS <br />Rt'.PAIREn ❑ <br />TES'IAFTER <br />CLOSEDTIGHT ❑ <br />CLOSEDTIGHT F1 <br />RV EXERCISED ❑ <br />sIRI\LFT PSID <br />REPAIRS <br />LEAKED ❑ <br />LEAKED G <br />OPENED All' PSID <br />PASSED ❑ <br />PSID <br />PSID <br />kl CHECK—PSID <br />C I I K VAL%E_—PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION PASS❑ F:Ut.n <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND Isolation vahv: Open f✓ Closed ❑ SOV#I Open 'J Closed ❑ SOV#2: Open i] Closed ❑ <br />REMARKS: <br />TESTERS SIGNATURE: <br />TESTERS NAME PRINTED <br />REPAIRED BY: <br />FINAL TEST BY: <br />AX..B www <br />L. Brown <br />. LINE PRESSURE 40 PSI CONFINED SPACE? No <br />CERT. NO. B5601 DATE _ 3/26/2015 <br />ESTFRSPHONE 0 (360)668-1117 <br />IC NO. <br />NO. <br />DATE. <br />DATE <br />CALIBRATION DATE I1-25.2014 GAUGE # 03050953 MODEL Mideesl 845 SERVICE RESTORED YES '] NO ❑ <br />I certify that this report is accurate, and I have used WAC 246-290490 approved test methods and test equipment. S <br />