2701 ROCKEFELLER AVE 2024-03-05 - Laserfiche WebLink

WATER PURVEYOR: ® SMITH FIRE SYSTEMS �� RD!! � BACKFLOW PREVENTION ASSEMBLY TEST REPORT 1106 54th Avenue East, Tacoma, WA 98424 Phone: (253) 248-2000 Fax: (253) 248-2360 ACCOUNT# NAME OF PREMISE 2701 ROCKEFELLER AVE NC-18005 SERVICE ADDRESS 2701 ROCKEFELLER AVENUE CITY EVERETT CONTACT PERSON KEATS LUGINBILL PHONE 360-535-1078 LOCATION OF ASSEMBLY RISER ROOM,,, NW CORNER OF LEVEL P1 DOWNSTREAM PROCESS k) b o /'"t /-iI V ` DCVA ❑ RPBA ❑ PVBA ❑ OTHER _ NEW INSTALL EXISTING❑ REPLACEMENT ❑ OLD SER. # PROPER INSTALaLlA.�TIIIOONJ?? YES / ' NO ❑ MAKE OF ASSEMBLY WILKINS MODEL 350ASTDA SERIAL NO. J / U !✓ SIZE 4" SEND TO: Commercial J9 Residential ❑ ZIP FAX DCVA DCVA RPBA PVBA/SVBA INITIAL CHECK VALVE NO. 1 CHECK VALVE NO.2 AIR INLET TEST OPENED AT PSID PASSED 6 ❑ LEAKED ❑ 2 LEAKED ❑ PSID # 1 CHECK AIR GAP OK? PSID OPENED AT DID NOT OPEN PSID ElFAILED NEW PARTS CLEAN REPLACE PAR -I ❑ ❑ CLEAN REPLACE RART ❑ ❑ CLEAN REPLACE ❑ ❑ PART CHECK VALVE HELD AT PSID LEAKED ❑ AND REPAIRS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _ CLEANED REPAIRED ❑ ❑ TEST AFTER REPAIRS LEAKED ❑ LEAKED ❑ OPENED AT PSID AIR INLET PSID PASSED ❑ PSID SID #I CHECK PSID CHK VALVE PSID FAILED ❑ AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Reading REMARKS LINE PRESSURE � PSI EDITION TEST PROCEDURES AT SDOH APPROVED DEVICE? YES ❑ NO ❑ CONFINED SPACE? NO Y TESTERS SIGNATURE: ' CERT. NO. �� DATE =ZZ f. TESTERS NAME PRINTED• ° 1 TESTING COMPANY'S PHONE #: (253) 248-2000 CALIBRATION DATE GAUGE # Q21 MODEL SERVICE RESTORED? YES❑ NO/6 REPAIRED BY: CERT. NO.: DATE FINAL TEST BY: CERT. NO.: DATE CALIBRATION DATE GAUGE # MODEL SERVICE RE, STORED? YES❑ NOD I certify that this report is accurate, and I have used wAC 46-290490 approved test methods and test equipment.