2804 GRAND AVE 2023-11-28 - Laserfiche WebLink

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 2804 Grand Ave Food Co-op Commercial M Residential ❑ SERVICE ADDRESS 2804 Grand Ave CITY Everett ZIP 98201 CONTACT PERSON John looney PHONE(425876-4247 (John) FAX( ) LOCATION OF ASSEMBLY In back of coop left storage room near elevator 6' up DOWNSTREAM PROCESS Water purifier DCVA ❑ RPBA ® PVBA O OTHER NEW INSTALL B EXISTING ❑ REPLACEMENT❑ REMOVED ❑ OLD SER.# APPROVED DEVICE? YES® NO❑ PROPER INSTALLATION? YES ® NO ❑ MAKE OF ASSEMBLY Watts MODEL LF009M2QT SERIAL NO. 301407 SIZE 1" INITIAL DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA TEST CHECK VALVE NO.l CHECK VALVE NO.2 AIR INLET OPENED AT 3.1 PSID PASSED ® CLOSED TIGHT ® CLOSED TIGHT® OPENED AT PSID #1 CHECK 9.3 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 REMARKS: Downstream process not yet installed LINE PRESSURE 82 PSI METER NUMBER CONFINED SPACE? No TESTERS SIGNATURE: CERT.NO. B7464 DATE 10-24-23 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 rest equipment.