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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />AC'CO Engineered Systcros <br />QDengineered 5300 Denver Ave S <br />sstems Seattle, WA 98108 <br />y 206-787-8500 <br />ASSEMBLY ID 9T� SCHEDULE CODE: AUTHORIZED TESTER: <br />NAME OF PREMISEI-f/ Commercial//t( Res�idIe,n�tial ❑ <br />SERVICE ADDRESS Ave _ CITI' YVPt^�G ZIP 82OI <br />CONTACTPERSON TLIGtwi KPi IriPC,Aa4 PHONE(2a6 )sro�FAX( ) — <br />LOCATION OF ASSEMBLY %n <br />DOWNSTREAM PROCESS DCVA ❑ RPBA P\'BA ? AG ". OTHER � <br />NE\V INSTALL LM EXISTING ❑ REPLACEMENT ❑ OLD JS�N / PROPER INSTALLATION? YES /® NO ❑ <br />MAKE OF ASSEMBLY Wa MODEL LF6(7q&TSERIAL NO. 37333+� SIZE J� <br />DCVA <br />/RPBA <br />DC\'A /RPBA <br />HIM <br />ITITIAL <br />CHECK <br />Y,�.\'E <br />NO.I <br />CHECK VrL-YE <br />N0.2 <br />OPENED AT 3 PSID <br />TEST <br />,LEAKED <br />❑ <br />pl CHECK PSID <br />OPSID <br />CPSID <br />LEAKED ❑ <br />L <br />PASSED <br />k. <br />Y <br />PSID <br />T <br />PSID <br />AIR GAP OK' YTs <br />D❑ <br />FAILED ❑ <br />—I— <br />.w <br />s <br />w <br />uL• <br />�,, <br />O <br />❑ <br />❑ ❑ <br />❑ ❑ <br />HELD AT <br />PSID <br />PARTS <br />❑ <br />❑ <br />_ <br />❑ ❑ <br />❑ ❑ <br />LEAKED <br />❑ <br />REPAIRS <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ — <br />REPAIRED <br />❑ <br />CLOSED <br />TIGHT <br />❑ <br />CLOSED TIGHT <br />❑ <br />OPENED AT <br />AIR INLET_ <br />PSID <br />REPAIRc <br />LEAKED <br />❑ <br />LEAKED <br />❑ <br />_PSID <br />PASSED ❑ <br />pI CHECKPSID <br />CHK VALVE _PSID <br />PSID <br />PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION: - PASS M FAIL ❑ <br />REMARKS: LINE PRESSURE 60 PSI <br />y� CONFINED SPACE? " <br />TESTERS SIGNATURE: CERT. NO. B7636 DATE .2 912 3 <br />TESTERS NAME PRINTED: Eric Riley TESTERS PHONE p ( 206 ) 787-8500 <br />REPAIRED BY: DATE <br />FINAL TEST B1 <br />CERT. NO. DATE <br />CALIBRATIONDATE 01 / 10 /2023 n1AKVT*fODEL Midwest/845.5 GAUGE# 06220902 <br />/ eeno"MArrpavr 11 "ear", and I Mee ared IIAC 24FT90J90 ypn,rd fea enrdiod, and It" efwp"N. <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />®engineered <br />l I systems <br />ACCO Engineered Systems <br />5300 Denver Ave S <br />Seattle, WA 98108 <br />206-787-8500 <br />ASSESIBLY ID X. SCHEDULE CODE: AUTHORIZED TESTER: k r 1 �_ 91f e— <br />NAMEOFPREMISE IS'M I40 l-lon'l Commercial M'�Resldentlal❑ J <br />SERVICE ADDRESS 7 O 2 O / r, L, l e Ater CITY ��_7.IP <br />CONTACT PERSON T r, ,eI 1<aIde'5joe4 PHONE(2o6 )yD, 7-Z5 FAX( 1 <br />LOCATION OF ASSENIBLI' <br />DOWNSTREAM�OCESS DCVA ❑ RPBA PVDA? AG? OTHER <br />NE\V INSTALL EXISTING ❑ M REPLACEENT ❑ OLD SN M PROPER INSTALLATION'. \"ES M/NO I❑ <br />MAKE OF ASSEMBLY (�Q 4S MODEL / F 1)0 FQ`I'SERIAL NO. , 1733?J O SIZE _ <br />DCVA IRPBA <br />DUN RPBA <br />CHECK VALVE N0.2 <br />RPBA <br />rs Dnms VA <br />AIR INLET <br />INITIAL <br />CIIECK VALAX N <br />OPENED AT,� PSID <br />TES T <br />LEAKED ❑ <br />MI CHECK PSID <br />OPENED AT <br />CHK VALVIf' <br />PSID <br />PSID <br />/ <br />LEAKED ❑ <br />PASSED <br />PSID <br />PSID <br />1 <br />AIR GAP OK? YP� <br />DID NOT OPEN <br />❑ <br />0 <br />FAILED ❑ <br />.. w . <br />n a <br />i w <br />H VA <br />\ E <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />HELD AT <br />PSID <br />PAR IS <br />AM <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />LEAKED <br />❑ <br />REPAIRS <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />REPAIRED <br />❑ <br />TEST AFTER <br />CLOSED TIGHT ❑ <br />CLOSED TIGHT ❑ <br />OPENED AT <br />AIR INLET <br />PSID <br />RFPAI <br />LEAKED ❑ <br />LEAKED ❑ <br />_PSID <br />PASSED ❑ <br />PSID <br />PSID <br />Ni CHECKPSID <br />CHK VALVE <br />_PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER - SEPARATION: PASS FAIL ❑ <br />REMARKS: <br />If STERS SIGNATURE: <br />LINE PRESSURE JaQPSI <br />CONFINED SPACE? ND <br />No. B7636 DATE 15/ 9/Z3 <br />TESTERS N'.AME PRINTED: Eric Riley TESTERS PHONE N ( 206 1 787-8500 <br />REPAIRED BY: DATE <br />FINAL TEST B' <br />CERT <br />CERT.NO. DATE <br />CALIBRATION DATE 01 1 10 I2023 IiIAMNIODEL MidweSU845-5 GAUGE/ 06220902 <br />1 reno Iha1 Ihh span It grew", and! I have aced IIAC 14d 90 110 approved we method, and Ira yaipartal <br />