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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br /> DENNIS P McLAUGHLIN GREATER SEATTLE AREA <br /> STATE CERTIFIED PHONE: (206) 364-9531 <br /> INDEPENDENT OPERATOR ��` � CELL PHONE: (206)419-0774 <br /> FAX: (206)367-1897 <br /> ACCOUNT# -�1 r J <br /> NAME OF PREMISE � I < f' � � '/- )� \ � �!U Commercial�l Residenllal❑ <br /> _ _ ,. <br /> _ _,�._ �� /� , . <br /> SERVICEADDRESS "" � /'� )' , �_fi ' . I � �.i `-�-�CII'Y L--'ve=E..}- I/ ZIP'fl,l�y'�� �,'`r <br /> r ;� � -' 'j �! i �� FAX ( ) <br /> CONTACT PERSON '_ /r � � PHONE Q� �) <br /> LOCATION OF ASSEMBLY ' � ! t.� " � � ' ' � ' � ' ' � � � � <br /> DOWNSTREAM PROCESS ` ' ! �_ DCVA O RPB/,�I PVBA O OTHER <br /> NEW INSTALI�EXISTING ❑ REPLACEMENT ❑ OLD SER.# PROPER INSTALIATION7 YES�NO ❑ <br /> FREEZE PROTECTED YES� NO ❑ <br /> �� ' � " � SIZE ��-' � <br /> MAKE OF ASSEMBLY `� � > MODEL � � I SERIAL NO. � f 1 - <br /> DCVAIRPBA DCVAIRPBA RPBA pVBA1SVBA <br /> INITIAL CHECK VALVE N0.7 CHECK VALVE N0.2 OPENED ATI�PSID AIR INLET <br /> TEST � <br /> CLOSED TIGHT-� CLOSED TIGHT'�l # � CHECK i�� PSID OPENED AT PSID <br /> LEAKEDIJ LEAKED ❑ DID NOT OPEN ❑ <br /> PASSED�1 AIR GAP OK7 '�`_ '> <br /> FAILED ❑ PSID PSID <br /> CLE�N REPLACE PARi QEAN REPLACE Po1ftT CLEAN REPLACE PART CHECK VAWE <br /> NEW � �7 �] ❑ ❑ ❑ _ HELD AT PSID <br /> PARTS ❑ ❑ � ❑ ❑ ❑ _ LEAKED ❑ <br /> AND � � ❑ ❑ ❑ ❑ <br /> REPAIRS — CLEANED O <br /> f7 f7 __ �� [-1 . �� �� — REPAIRED ❑ <br /> 7EST AF7ER CIOSED TIGHT ❑ CLOSED TIGHT f7 pp�NED AT_PSID AIR INLET PSID <br /> REPAIRS LEAKEDI7 LEAKED ❑ <br /> PASSED ❑ # 1 CHECK PSID CHK VALVE PSID <br /> FAILED ❑ — PSID PSID <br /> AIR G�AP OK? <br /> AIR GAP INSPECTION: Roq�i��a r�i�imim+wirqevsoperma�pro��aed� Y�3 U No ❑ DotBcfO�Metef Reeding <br /> Detector Meter# <br /> REMARKS: LINE PRESSURE�_PSI <br /> CONFINED SPACE?�_` <br /> '" � � _��'. <br /> TESTERS SIGNATURE: � ,{ `; ' '"_ , .�j I !��� CERT.NO. ' ' ` DATE � <br /> TESTERS NAME PRINTEDt� '+ � � ' � - -- TESTERS PHONE X(' � ) �' �-' - % <br /> REPAIRED BY: DATc <br /> FINAL TEST BY: CERT. NO. DA1'E <br /> MID�N�ST <br /> CALIBRATION DATE_/_I ' GAUGE# � MODEL ` SERVICE RESTORED7 YES❑ NO� <br /> 1 certily fhnf Ihis rnport is nccurnfe,enA 1 hpve used WAC.46-290-490 epproved tesf inefhods end fest equipmenf. .' r— <br /> WASHINGTON STA TE RECOGNIZED REPORT FORM <br />