9605 EVERGREEN WAY PHO SMILE 2023-09-15

of forda6�e v/�r��/ PO Box 1255 [N PASS E]FAIL astiin jkn Cie E l u m,WA 98922 If you have any questions about your results (360) 333-2057 or your device failed please contact us now. Bac�ow I.I.(; BACKFLOW PREVENTION ASSEMBLY TEST REPORT WATER PURVEYOR Everett ACCOUNT# NAME OF PREMISE Pho Smile Commercial❑ Residential SERVICE ADDRESS 9605 Evergreen Way Unit E CITY Everett ZIP 98204 CONTACT PERSON Cai, Duy PHONE(425777-1211 FAX( ) LOCATION OF ASSEMBLY In kitchen right of dishwasher upper DOWNSTREAM PROCESS Dishwasher DCVA ❑ RPBA 13 PVBA O OTHER NEW INSTALL ® EXISTING ❑ REPLACEMENT❑ REMOVED ❑ OLD SER.# APPROVED DEVICE? YES® NO ❑ PROPER INSTALLATION? YES ® NO ❑ MAKE OF ASSEMBLY Wilkins MODEL 975XL2 SERIAL NO. ABW3494 SIZE 3/4" INITIAL DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA TEST CHECK VALVE NO.1 CHECK VALVE NO.2 AIR INLET OPENED AT 3.5 PSID PASSED ® CLOSED TIGHT ® CLOSED TIGHT® OPENED AT PSID #1 CHECK 9.8 PSID LEAKED ❑ LEAKED ❑ DID NOT OPEN ❑ FAILED ❑ PSID PSID AIR GAP OK? X NEW CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE PARTS ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID AND ❑ ❑ ❑ ❑ ❑ ❑ LEAKED ❑ REPAIRS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CLEANED ❑ REPAIRED ❑ TEST AFTER REPAIRS CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT PSID AIR INLET PSID PASSED ❑ PSID PSID #1 CHECK PSID CHK VALVE PSID FAILED O AIR GAP INSPECTION:Required minimum air gap separation provided? Yes❑ No ❑ Detector Meter Reading LEFT SERVICE AS FOUND: ISO VALVE Open®Closed❑ SOV 1 Open ®Closed ❑ SOV 2 Open®Closed O REMARKS: LINE PRESSURE 71 PSI METER NUMBER CONFINED SPACE? No TESTERS SIGNATURE: CERT.NO. B7464 DATE 07-31-23 TESTERS NAME PRINTED: Taro Smithson TESTERS PHONE#( 360}333-2057 REPAIRED BY: DATE FINAL TEST BY: CERT.NO. DATE CALIBRATION DATE 01-06-2023 GAUGE# 04192518 MODEL 845 SERVICE RESTORED? YES® NO❑ I certify that this report is accurate,and I hare used WAC 246-290-490 approved rest methods and test equipment.