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AACRA BaCNllow Testing and Repair, Inc. BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />(360)668A117 <br />WATER PURVEYOR 'iorthshore Utility District ACCOUNT <br />ASSEMBLYID/FILEp/UTILTN DEVICE III _ <br />Meter N <br />NAMF OF PREMISE Spenccf 68 Apls. Commercial dl Residential ❑ <br />SERVICE ADDRESS 18149 68th Ave. NE _Kenmore ZIP 98028 <br />CONTACT PERSON Doug _ PHONE. (206) 571-1692 <br />LOCATION OF ASSEMRLy G. Grid Bldg. B Riser Room <br />DOWNSTREAM PROCESS Fire Service DCVA ❑ RPBA ❑ PVBA ❑ OTHER DCDA <br />NEW INSTALL. ❑d EXISTING ❑ RF.PLACEMF.N1 '=! REMOVED D OLD SERA' <br />APPROVED ASSEMBLY? VES 2 NO D PROPERINSTALLATION? YES J NO <br />MAKE OF ASSEMRLV Wilkins MODEL »OAti-FDA SERIAL. NO. 293213 SIZE 2.S' <br />DCVA / RPB.A <br />DCVA ! RPB.A <br />RPBA <br />11% BA ! SA'BA <br />INITIAL <br />CHECK VALVE. <br />NO.I <br />CHECK VALVE N0.2 <br />AIR INLET <br />TEST <br />orENEnAr PSID <br />CLOSEDTIGIIT <br />25 <br />CLOSED -TIGHT .V <br />OPENED AT <br />PSID <br />PASSED <br />— <br />LI CHECK PSID <br />LEAKED <br />❑ <br />LEAKED <br />DID NOT OPEN <br />❑ <br />FAILED <br />] <br />2.5 <br />PSID <br />7•8 PSID <br />:AIR GAPOK". <br />CLEAN REPLACE <br />PART <br />CLEAN REPLACE PART <br />CLEAN REPLACE PAP! <br />CHECKN'ALVE <br />NEW' <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ _ <br />HFLDAI <br />PSID <br />PARTS <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />AND <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />U <br />REPAIRS <br />REPAIRED <br />❑ <br />TESTAFTER <br />CLOSEDTIGHT <br />--J <br />CLOSEDTIGHT ❑ <br />RVFXERCISED j-i <br />AIR INLET <br />PSID <br />IMPAIRS <br />LEAKED <br />_ 1 <br />LEAKED ❑ <br />opENE.n AT PSID <br />PASSED <br />❑ <br />PSID <br />PSID <br />VICHECK PSID <br />cIIK VALVE <br />[)SIT) <br />FAILED <br />❑ <br />AIR GAP INSPECTION: SUPPLY PIPE. DIAMETER SEPARATION PASS❑ FAIL❑ <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND I50117i0n rnlve: Open ❑ Closed 2 SOVNI Open ❑ Closed R SOVH2: Open ❑ Closed [siJ <br />REMARKS: <br />LINE PRESSURE 116 PSI CONFINED SPACE'? No <br />TESTERS SIGNATURE: 49X.8/tftW CERT. NO. B5601 DA I•E 312612015 <br />TESTERS NAME PRINTED Gan' L. Brown TESTERS PHONE a (360)668-1117 <br />REPAIRED BY: <br />NO. <br />DAT <br />FINAL TEST BY: CERT. NO. DATE <br />CALIBRATION DATE 11.25-2014 GAUGE # 03050953 MODEL Midwest 845 SERVICE. RESTORED YES ❑ NO n <br />1 certify Ihat Ihis re part is accurate, and 1 have used %VAC 246r290-490 approved lest methods and test equipricnt. �/J <br />