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. . <br /> .. <br /> Seattle Return reports to: <br /> Public BACKFLOW PREVENTION ASSEMBLY csB--Inspection services <br /> • • • TEST REPORT 700 51'Ave,Suite#4900 <br /> Utilities • <br /> P.O.Box34018 <br /> Seattle,WA 98124-4018 <br /> • Phone:(206)684-3536 <br /> • FAX: (206)684.7585 <br /> 'ASSEMBLY ID#: <br /> AA <br /> Facility Name: 1c )--,i�� ), a,vl Commercial: Residential: <br /> Service Address:.(. ( )0 .s ..yry-•�lJ S,-,.eyk:! Ci#y. Zip: <br /> Ci <br /> 3 <br /> l <br /> Contact Name: Phone: Fax: <br /> Assembly Location: :J •, ��\ byn'e ` fTs '�... i i Y S� Y-1/VOHazard Type: F.... .1 ..`uJ DCV PBA 0 PVBA❑AG❑Other. <br /> New Install nist- g ❑ Replacement 0 Old SN# Proper Install? Yes,leffriiroT <br /> Make of Assembly: 474`7.0 <br /> Model: filreal# 5;73c( Size: <br /> INITIAL TEST B t\CVA PBA' RPBA PVBA/SVBA. . <br /> K V #1 CHECK VALVE#2 Air Inlet <br /> Opened at PSID <br /> PASSEKr Closed Ttght.Er' Closed Tight--Er at PSID'� #1 Check PSID <br /> FAILED ❑ . Leaked 0 Leaked ❑. Chk Valve PSID <br /> 4 PSID • Z PSID- Air GapOK <br /> Did not Open .❑ <br /> Clean Replace Pan ! Clean Reptac's Part . r Clean Replace Part . Check Valve <br /> NEW PARTS ❑ Q ❑ Q • . ❑ ❑ Held at . PSID <br /> AND REPAIRS .0 0 . • 0 ❑ . 0 0 Leaked ❑ <br /> ❑ ❑ ❑ ❑ . • ❑ ❑ Cleaned,❑ <br /> • <br /> ❑ ❑ 0 0 ❑. 0 Repaired❑ <br /> TEST AFTER Closed Tight ❑ Closed Tight 0 <br /> REPAIRS' Leaked 0 • Leaked Q Opened at PSID Air Inlet PSID <br /> PASSED 0 PSID PSID #1 Check PSID Chk Valve PS1D <br /> FAILED 0 <br /> Air Gap Inspection: Supply Pipe Diameter " Separation: A—° Pass Fail Q <br /> REMARKS: • _ Line Pressure:, PSI • <br /> • Confined S ce:Yes:❑ No O <br /> B5201 ; IL <br /> Tester's Signature: ,u, ..��� -- �- � Cent. No. Date: f / 1 <br /> Tester's Name Printed: Shane Foss Tester's Phone#: ( 2 5 3 ) 8 5 7-2 0 5 6 <br /> Repaired By: Cert No. Date: / / <br /> Final Test By: Cert. No. Date: / / _ <br /> �� ) Mid West 835 06081890 <br /> Calibration Date: �'4'` 01 Make!Model: Gauge# . <br /> I certify that this rep rt is ac urate and I have used WAG 245-290-490 approved test methods and test equipment. <br /> Emerald Fire LLC ' <br /> 11021 Cramer Road KPN <br /> /73 <br /> Gig Harbor, WA 98329 <br />