1321 SE EVERETT MALL WAY ANGRY CRAB SHACK 2024-01-08

A_� �BACKFLOW PREVENTION ASSEMBLY TEST REPORT e3e WATER PURVEYOR Everett ACCOUNT# ASSEMBLY ID/FILE HNTILITy DEVICE p MemrR NAME OF PREMISE An C b Commertial ® Reaitlentlel ❑ SERVICEADDRESS 1321 SE Everett Mall Wav Everett ZIP 98208 CONTACT PERSON Curtis (Bond PI b' ) PHONE (206) 779-7441 LOCATION OF ASSEMBLY NCar dishwasher DOWNSTREAM PROCESS Dishwasher DCVA ❑ RPBA IH PVBA ❑ OTHER NEW INSTALL ® EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLD SERA APPROVED ASSEMBLY? EVES ®NO❑ PROPER INSTALLATION? YES 65NO ❑ MAKE OP ASIA.SEMBLY A tS MODEL L(-QC9 13 SERIAL NO. SIZE INITIT VA/RPBA DCVA/RPBA RPBA PVBA/SVGA TESTK VALVE NOI CHECKVALVE NOS AIRINLET TIGHT CLOSEDTIGHT PENED AT ZS PSID OPENED ATPASSED ❑ LEAKED ❑ sI CHECK PsroFAILED^�SID �� PSID AIRGAPOK?Ye�> DID NOT OPEN ❑ mcrwLt PART QFAN RP"cl PART BEAN REPIA[E PART CHECK VALVE❑ ❑ ❑ ❑ ❑ ❑ IIELDAT PSro ❑ ❑ ❑ ❑ ❑LEAKED ❑❑❑ ❑ ❑ ❑❑❑❑ ❑ CLEANEDREPAIREDOSEDTIGHT 4MEOj ❑ CLOSEDTIGHT ❑ RV EXERCISED ❑pIR INLET PSID EAKED ❑ LEAKED ❑ PENED AT PSID PSID PSID NI CHECK PSID CHKVALVE PSID AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION PASS ❑ FAIL ❑ DETECTOR METER READING LEFT SERVICE AS FOUND Isolation valve: Open ® Closed ❑ SOV#1: Open ®Closed ❑ SOV#2: Open RS Closed ❑ REMARKS: LINE PRESSURE 8� PSI CONFINED SPACE? No � /. TESTERS SIGNATURE: /7 ,,�j /?< CERT. NO. B6423 DATE 1011712023 TESTERS NAME PRINTED Joshua Cobb TESTERS PHONE # (360)631-0039 REPAIRED BY: LIC NO. DATE FINAL TEST BY: CERT. NO. DATE CALIBRATION DATE I1-22-2022 GAUGE # 12180097 MODFL Midn'est 845- SERVICE RESTORED YES ® NO ❑ I certify that this report is accurate, and 1 base used W.AC 29629044M1 approved lest method. and Ian equipment.