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Seattle Return reports to: <br /> 6 Public BACKFLOW PREVENTION ASSEMBLY csf3--inspection services <br /> TEST REPORT 700 5th Ave,Suite#4900 <br /> Utilities • <br /> P.O.Box 34018 <br /> Seattle,WA 98124-4018 <br /> - Phone:(206)684-3536 <br /> FAX: (206)884-7585 <br /> ASSEMBLY ID# \ c C. .... \ <br /> Facility Name: 1\OW \ ' Y.' Commercial: , Residential: 0 <br /> Service Address: 7 G )° �� r ir) Ctty:� Zip: ' <br /> Contact Name: Phone: ., ` Fax: <br /> Assembly Location:9g-. ''1 '-, >-rt- 1 'J `1✓"0-7 <br /> Hazard Type: F5)--,-re.„ 1R/ In DCVA❑PVBA❑AG 0 Other: <br /> New Instal istin ❑ Replacement 0 Old SN# Proper Install? Yes x]�o: 0 , <br /> Make of Assembly: ,°' Mode, i 1# / Size: <br /> INITIAL TEST DCVA I RPBA DCVA I RPBA ' RPBA - PVBA/SVBA. . <br /> CHECK VALVE#1 CHECK VALVES/2 Air Inlet <br /> Opened at PSID <br /> PASSED;2 Closed Tight.'— Closed Tight,c1 : Opened at PSID <br /> #1 Check PS1D <br /> FAILED Leaked 0 Leaked ❑ Chk Valve PSID <br /> ' <br /> Air Gap'OK • <br /> psio PSID Dld not Open .0 <br /> . Clean Replace Part 'Clean Replace Part . Clean Replace Part - : • Check Valve <br /> NEW PARTS ❑ ❑ ❑ ❑ • - ❑ ❑ Held at PSID <br /> • <br /> . AND REPAIRS .0 (] . • 0 0. 0 0 Leaked 0 <br /> ❑ ❑ ❑ ❑ . - ❑ ❑ Cleaned.❑ <br /> ❑ ❑ 0 0 ❑. 0 Repaired[) <br /> TEST AFTER Closed Tight 0 Closed light 0 <br /> REPAIRS- Leaked 0 Leaked ❑ Opened at - PSID Air Inlet PSID <br /> PASSED ❑ PSID #1 Check PSID Chk Valve PSID <br /> PSID <br /> FAILED ❑ . _ <br /> Air Gap Inspection: Supply Pipe Diameter: " Separation: 1irA"-- " Pass 0 Fail 0 <br /> REMARKS: • 'Line Pressure: 0 PSI <br /> • <br /> • Confined Space:Yes:0 NiT[r <br /> Tester's Signature: Cert No. B 5 2 0 l Date: I Pry v / 3c/ ). <br /> Tester's Name Printed: Shane Foss Tester's Phone it( 2 5 3 ) 8 5 7-2 0 5 6 <br /> Repaired By: Cert. No. Date: / / <br /> Final Test By: �j Cert. No. Date: / / <br /> Calibration Date: _i make/Model: Mid West 8 3 5 Gauge# 0 6 0 818 9 0 <br /> I certify that this repdrt is accurate and I have used WAG 246-290-490 approved test methods and test equipment. <br /> Emerald Fire LLC ' <br /> 11021 Cramer Road KPN <br /> Harbor, WA 98329 (:::::3 <br /> �" <br />