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BACKFLOWS NORTHWEST <br />12819 SE 38'^ St #57 — WA 98006 — PHONE 425-277-2888—FAX 425-671-0809 <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />ACCOUNT# Assembly ID Invoice Purveyor <br />NAME OF PREMISE S O & ti S e c. h %r 6 h Commercial ❑ Residential ❑ <br />SERVICE ADDRESS 1 1 G fL S 'A,, If nY-I rive d CITY I —Cc V-nre -tat ZIP 9 St 2414 <br />CONTACT PERSON PHONE( ) FAR( ) <br />LOCATION OF ASSEMBLY 1 It IC t f h O I'I <br />DOWNSTREAM PROCESS 1*3O A f Y 1 L DCVA Bi RPBA ❑ PVBA ❑ DCDA ❑ OTHER <br />NEW INSTALL L?" EXISTING ❑ REPLACEMENT ❑ OLD SER # PROPER INSTALL? YES ❑ NO ❑ <br />MAKE OF ASSEMBLY W �. f- t S MODEL 1-Foe el M 7. C& ERIAL NO. I O C3 O I-S SIZE 1 17 <br />DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA <br />INITIAL CHECK VALVE NO.] CHECK VALVE NO,2 AIR INLET <br />TEST ,/ OPENED AT 3.O PSID <br />CLOSED TIGHT Er CLOSED TIGHT fY OPENED AT PSID <br />LEAKED ❑ LEAKED ❑ #I CHECK 9-2- PSID <br />PASSED d f DID NOT OPEN ❑ <br />FAILED ❑ .K �•- PSID g - 1 pSID AIR GAP OK? <br />CHK VALVE PSID <br />CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br />NEW ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID <br />PARTS ❑ ❑ ❑ ❑ ❑ ❑ LEAKED ❑ <br />AND ❑ ❑ ❑ ❑ ❑ ❑ <br />REPAIRS CLEANED ❑ <br />❑ ❑ ❑ ❑ ❑ ❑ REPAIRED ❑ <br />TEST AFTER <br />REPAIRS LEAKED ❑ LEAKED ❑ OPENED AT _PSID AIR INLET PSID <br />PASSED ❑ PSID pSID #1 CHECK PSID CHK VALVE PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum air gap separation provided? Yes N No ❑ Detector Meter Reading <br />REMARKS: LINE PRESSURE PSI <br />CONFINED SPACE? <br />TESTERS SIGNATURE: ' "Z�" CERT. NO. _B7283_DATE LI /I / Z 4 <br />TESTERS NAME PRINTED: Kevin VenninE TESTERS PHONE # (425) 277-2888 <br />REPAIRED BY: DATE <br />FINAL TEST BY: CERT. NO. DATE <br />CALIBRATION DATE: 04-05-2021 GAUGE # 02211052 MODEL: Midwest 845-5 SERVICE RESTORED? YES ❑ NO ❑ <br />I certify that this report is accurate, and I have used WAC 246-290-490 approved lest methods and test equipment <br />