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AACRA Backnow Testing and Repair, Inc BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />WATER PURVEYOR Northshore Utility District ACCOUNT <br />ASSEMBLY ID/FILE #/UTII-ITT DEVICE # <br />Meter # <br />NAME OF PREMISE Spencer 68 Apls. Commercial C. Residential <br />SERVICE ADDRESS 18149 68th A\'e. NF Kenmore ZIP 98028 <br />CONTACT PERSON Dou,! PHONE. (206) 571-1682 <br />LOCATION OF ASSEMBLY F. End Bid,. B Riser Room <br />DOWNSTREAM PROCESS Fire Service Bypass UCVA G RPBA ❑ PVBA ❑ OTHER <br />NEW INSTALL E/D EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLDSER.# <br />APPROVED ASSEMBLY? YES S11 NO ❑ PROPER INSTALLATION? YES L% NO ❑ <br />MAKEOFASSLNIHLY Wilkins N101)F1, 950XLD SF.RLVLNO, 4018728 SIZE .75" <br />DCVA/RPHA <br />DCVAIRPBA <br />RPHA <br />PVBA,SIBA <br />INITIAL <br />CHFCK VALVE: <br />NOA <br />CHECK VALVE NO.2 <br />AIR INLET <br />TEST <br />oPENEDAT <br />PSID <br />CLOSED 11611T <br />'� <br />CLOSED TIGHT <br />OPENED U <br />PSID <br />PASSED ❑y <br />LEAKED <br />--. � <br />LEAKED ❑ <br />nl CHF.CK_�)SID <br />DID NOT OPEN <br />FAILED ❑ <br />2. 1 <br />PSID <br />3.6 PSID <br />AIR GAP OK? <br />CLEAN REPLACE <br />PART <br />CLEAN REPLACE PART <br />CLEAN REPLACE <br />PART <br />CHECK VALVE <br />NEW <br />❑ U <br />❑ ❑ <br />❑ ❑ <br />IIF:LDA'E <br />i'SID <br />PARTS <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />LEAKED <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />AND <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />cLF:ANE:D <br />REPAIRS <br />REPAIRED <br />❑ <br />TF.ST'AFIER <br />CLOSED TIGHT <br />❑ <br />CLOSEDTIGHT <br />RV EXERCISED <br />❑ <br />AIR INLET <br />PSID <br />REPAIRS—, <br />LEAKED <br />J <br />LEAKED a <br />OPENEDAT <br />PSID <br />PASSF,O ❑ <br />PSID <br />PSID <br />hi CHECK <br />PSID <br />c11K VANE <br />PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION PASS❑ FAIL❑ <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND tsolaGnn salve: Open EZ Closed ❑ SOV41 Open ❑ Closed © SOV#2: Open ❑ Closed Q <br />REMARKS: <br />LINE PRESSURE 120 PSI CONFINED SPACE.? No <br />TESTERS SIGNATURE: jktaviiwou f CERT. NO. B5601 DATE 3/26/2015 <br />TESTERS NAME PRINTED Gary L. Brown TESTERS PHONE a (360)668-1117 <br />REPAIRED BY: <br />FINAL TEST BY: <br />i" <br />NO. <br />DATE: <br />DAT <br />CALIBRATION DATE 11-25.2014 GAUGE'" 03050953 MODEL Midwest 845 SERVICE RESTORED YES ❑ NO G <br />s <br />I certify that this report is accurate, and I have used AC 246-290-0m 90 approved test methods and test equipment. U N' <br />