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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br /> DENNIS P McLAUGHIIN GREATER SEATTIE AREA <br /> STATE CERTIFIED PHONE: (206) 364-9537 <br /> INDEPENDENT OPERATOR CELL PHONE: (206)419A774 <br /> � FAX: (206) 367-1837 <br /> ACCOUNT� -'—�` �� • <br /> - � /,� <br /> NAME OF PREMISE ` � �.C.� l�%f� � � �lU Cammercia��Residentlal❑ <br /> SERVICE ADDRESS � � � _ ��/� '�/ / ' ��,�` CITYf l-'�F�""f� 21P 'I'' " � <br /> CONTACT PERSON I� . � � ; _���I-�� 7T� PHONE ('�'�) 'i��' " I �,� ��FAX( ) <br /> LOCATIONOFASSEMBLY ' '(�,,�/`/� �.'_ �I%� 1.�� r-�� . � I�1� ,'j ' `. il � , ;�� lI r�.- f:,• � ,; <br /> DOWNSTREAM PROCESS�' �_ `- 1= �-- DCVA� RPBA�PVBA ❑ OTHER <br /> NEW INSTALL�J EXISTING ❑ REPLACEMENT ❑ OLD SER.q PROPER INSTALLATION7 YES�l.NO ❑ <br /> FREEZE PROTECTED YES�iI NO ❑ <br /> I � l l� 'i ^ �—�— /� ,., � i <br /> MAKE OF ASSEMBLY � � ' � -`� MODEL � � SERIAL NO. � ' %I SI2E � �' <br /> DCVA/RPBA DCVAIRPBA RPBA PVBAISVBA <br /> INITIAL CHECK VAWE N0.7 CHECK VAWE N0.2 OPENED ATL�-�PSID AIR INLET <br /> TEST <br /> CLOSED TIGHT��1 CLOSED TIGHT,�1� � � CHECKIi•. ,� PSID OPENED AT__PSID <br /> LEAKED ❑ LEAKED f7 <br /> PASSED� AIR GAP OK? ,,�[;-', DID NOT OPEN ❑ <br /> FAILED ❑ _PSID _ PSID <br /> CLEAN REPLACE PART CLP.AN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br /> NEW �7 � �7 ❑ ❑ ❑ HELD AT PSID <br /> PARTS i7 ❑ ❑ ❑ ❑ ❑ _ LEAKED ❑ <br /> AND <br /> REPAIRS �l ❑ O n � � — CLEANED ❑ <br /> LI ❑ O ❑ __ � �-� — REPAIRED Ll <br /> TEST AFTER CLOSED TIGHT ❑ CLOSED I IGHT ❑ UPENED AT PSID AIR INLET PSIO <br /> REPAIRS LEAKED ❑ LEAKED L� — <br /> PASSED ❑ pSID PSID # � CHECK PSID CHK VAIVE PSID <br /> FAILED ❑ <br /> AIR GAP OK1 <br /> AIR GAP INSPECTION: aoqi��rx mimmum a�qap sopnrxeon pm�dod� Yes ❑ No ❑ Detector Meter Reading <br /> Detector Meter# <br /> REMARKS: LINE PRESSURE�PSI <br /> CONFINED SPACE7 � <br /> TESTERS SIGNATURE: �� ` ' '� �� �'7 '� .� ' �� CERT. NO.`� ' ' DATE �� �� I/ li" <br /> TESTERS NAME PRINTED: ;- ' ' ' . h• �? ' � TESTERS PHONE A( , i ) ": '� �� _ 'I <br /> REPAIRED BY: DATE <br /> FINAL TEST BY: CERT. NO. DATE <br /> MIDWEST <br /> CALIBRATION DATE_l;l_`GAUGE# MODEL SERVICE RESTORED?YE3�] NO ❑ <br /> 1 cc�Fly(hnt Ihis ropart is accurafe.nnd 1 have used WAC 746�790�490 e, prowtl fest melhods ond fesl epuipment l <br /> WASHINGTON STATE RECOGNIIED REPORT FORR� <br />