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BACKFLOW PREVENTION <br />ASSEMBLY <br />TEST REPORT <br />PURL/C WORKS <br />XC2 Assembly Schedule Code _Authorized Tester: <br />Return reports to: <br />Backilow Prevention Progaatn <br />Everett, WA <br />Public Works <br />3200 Cedar St. <br />Everett. WA 98201 <br />rAX: (425) 257-8882 <br />Facility Name Colby Club Commercial: ® Residential: ❑ <br />MailingAddress 2823 Colby Ave Everett. WA 98201 Protection Type <br />Service Address 2823 Colby Ave Everett, WA 98201 City: Everett Zip: 98201 <br />Contact Name Phone: Fax: <br />Equip Location Under bar, East end. <br />Downstrm Process DCVA ❑ RPBA ❑X PVBA ❑ AG ❑ Other <br />New Install ❑X Existing ❑ Replacement ❑ Old SN# <br />Proper Installation'' ❑X Yes ❑ No <br />Make of Assembly: Watts Model: LF009QT Serial Number 381849 Size: 1/2" <br />DCVA / RPBA <br />DCVA / RPBA <br />RPBA <br />PVBA/SVBA <br />CHECK VALVE ;;I <br />Initial Test <br />CHECK VALVE #2 <br />Opened at 1.8 PSID <br />Air Inlet <br />Passed ❑ <br />Leaked ❑ <br />Leaked ❑ <br />#1 Check PSID <br />Opened at PSID <br />Failed ❑X <br />PSID <br />PSID <br />Air Gap OK <br />Clean Replace Part <br />Did not Open ❑ <br />Clean Replace Part <br />Clean Replace Part <br />Check Valve <br />New <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />Held at PSID <br />Parts <br />❑ ❑ <br />El El <br />1:1 El <br />and <br />Leaked ❑ <br />Repairs <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />Cleaned ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ - <br />Repaired ❑ <br />Test After <br />Repairs <br />Leaked ❑ <br />Leaked ❑ <br />Opened at 2.7 PSID <br />Air Inlet PSID <br />Passed ® <br />8.9 PSID <br />PSID <br />91 Check 8.9 PSID <br />Check Valve PSID <br />Failed ❑ <br />Air Gap Inspection: Supply Pipe Diameter: <br />Remarks: Flushed relief valve <br />Tester Signature: <br />Tesler Name Printed: <br />Separation: <br />❑ USC i & Edit. <br />Pass ❑ Fail ❑ <br />Line Pressure 60 PSI <br />❑ Confined Space <br />Cert. No.: 6113 Date: 08-03-23 <br />Testers Phone # 2068186549 <br />Repaired By: Andrew Brown Date: 08-03-23 <br />Final Test By: Andrew Brown Cert. No.: 6113 Date: 08-03-23 <br />Calibration Date: 02-10-2023 Make/Model: Mid -West 845-5 Gauge # 02082408 <br />