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N aim <br />9NIWVaj 9NI1133IM3N <br />BACKFLOWS NORTHWEST <br />12919 SE 381b Se #57- WA 98006- PHONE 425.277-2888-FAX 425-671-NO9 <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />A( t'YTn Aacembl) ID In aMO# Nrveyor <br />NAME Of PREMISE Commar id ❑ Rmlden0nl ❑ <br />SERVICE ADDRESS 2 61 k E sii I• A@ COT P •' • ZIP g g Y e I <br />C'ONTAR PERSON <br />PHONE? 1 FAX( I <br />LOCATION OF ASSEMBLY A, R J < F • > <br />DOW'NsTHE.AM PROCESS T C e ^ CC k l•< O A "BA B PV IA O DCDA O OTHER <br />�2 NEW INSTALLRI EXISTING❑ REPLACEMENT❑OLD SER# PROPER INSTALL? YE,,S'9'NO❑ <br />MAKE OFASSEMBLY UAra 15 MODEL !•. OO 9 Rf TRIAL NO. i 9 1 ] 2 4 SIZE y — <br />T <br />P <br />F <br />AIR GAP INSPECTION: Re9ulrtd minimum Or w mPre wm°"I*o'Yn8 NO❑ Detootur Meter Reudioy <br />LINE PRESSURE %O PSI <br />REMARKS: <br />CONFINED SPACE? <br />INITIAL <br />TEST <br />pCVA/RPBA <br />rmerK VALVE NO.1 <br />CLOSED TIGHT E3 <br />N /RPBA <br />CHECK VALVE NOS <br />EEBA <br />OPENED AT7� PSID <br />#1 CHECK 7-6PSID <br />AIR INLET <br />AIR <br />OPENED AT_PSID <br />CLOSED TIGHT 0 <br />LEAKED ❑ <br />LEAKED ❑ <br />DID NOT OPEN <br />❑ <br />PASSED EI <br />�� <br />P5f0 <br />AIR GAP OK? <br />FAILED ❑ <br />CHK VALVE_PSID <br />nxnN Pmua emr <br />aetx nerua rnllr <br />aFAN neslAa' P,mr <br />CHECK VALVE <br />HELD AT <br />PSID <br />NEW <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />LEAKED <br />❑ <br />PARTS <br />❑A"O ❑ <br />❑ ❑ <br />❑ ❑ <br />14 <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />❑ <br />HE <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />REPAIRED <br />❑ <br />EtiT AFTER <br />❑ <br />OPENED AT _PSID <br />AIRINLET�PSID <br />REPAIRS <br />LEAKED ❑ <br />LEAKED <br />RI CHECK.PSID <br />CHKVALVE_PSIL <br />ASSED O <br />PSID <br />PSID <br />AILED ❑ <br />TESTERS SIGNATURE: ,rv- v CERT. NO. B7183_DATE <br />TESTERS PHONE#(425) 889 <br />"FESTERS NAME PRINTED: �KeviD WORM <br />DATE_._ - - - <br />REPAIRED BY: DATE <br />CERT. NO. — — <br />FINAL TEST BY: <br />CALIBRATION DATE:4Wa3 GAUGE#02AC19060031 MODEL:MekD MKS SERVICE RESTORED? YES NO 13 <br />BACKFLOWS NORTHWEST <br />12819 SE 38'^ St N57- WA 98006- PHONE 425-277-2888-FAX 42"71-0809 <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />ACCOUNT A. Auembly ID <br />mvofre0 <br />Purveyor <br />NAMEOFPREMISE <br />Cammntinl❑ RdHd lhll❑ <br />SERVICE ADDRESS I(, 1 6 COI <br />t. r AY{ <br />rr <br />CITY 1— Y4I2 <br />>'? ZIP 0. 4 LP 1 <br />CONTACT PERSON <br />PHONE? ) <br />FAXt 1 <br />LOCATION OF ASSEMBLY k PL jlr—w.7*'t <br />DOWNSTREAMPROCESS DrSk W&7 <br />DCVA D <br />RPBAIt PVBA❑ <br />DCOAO GTRER� <br />NEW INSTALL11 EXISTING REPLACEMENT ❑OLD SERM <br />PROPER INSTALL! VESB NO <br />MAKE OF ASSF.MBLIVA t¢5 MODELL.Fna}et SERIALNO.SSC+NNS <br />SIZE L/ , <br />DCVAI RPBA <br />DCVAI RPBA <br />0.PBAf— <br />INITIAL CHECK VALVE NO.1 <br />CHECKV LVE NO2 <br />2CLOSEDi'IGHT <br />AIR INLET <br />TEST <br />OPENED AT <br />J7 <br />CLOSED TIGHT 9 <br />ED AT_PR1UPASSEDA <br />LEAKED ❑ <br />LEAKED ❑ <br />NI CHECK 6.NOT <br />❑FAILED❑ <br />OPEN <br />6' S PSID <br />PSID AIR GAP OKT <br />VALVE PSiDx <br />ri❑ u f PART <br />w <br />nlaw uaua vcr <br />wn Nivue <br />`❑ <br />CHECKVALVENF.W <br />❑ <br />❑ ❑ <br />❑DAT <br />PSIDPARTS <br />❑ANDREPAIRS <br />❑ ❑❑ <br />❑ <br />❑ ❑AKED <br />❑ ❑ <br />❑ ❑ <br />❑ ❑EANED <br />❑❑ <br />❑ <br />❑ ❑ <br />❑ ❑PAIRED <br />❑TI"_S'1' <br />AFTERREPAIRS LF.AKRD ❑ <br />LEAKCD ❑ <br />OPENED AMINLET _PSIDPASSED❑ <br />PSID #1 CHECKHKVALVE_PRE <br />I'DVBNSVBA <br />P$1D <br />AIR GAP INSPECTION. <br />Roqu4Wmimmum obyn xomunon Pm"uluOYes9] <br />NO❑ <br />Det¢tur McHr RoodinR <br />WNEPRESSUR14C2 <br />PSI <br />TESTER3SIGNATURE:� �v _ CERT. NO. B7283_DATE <br />TESTERS NAME PRINTED: _Kevin VenNlOo TESTERS PHONE#(425) 277-2888 <br />DATE <br />REPAIRED BY: <br />CERT. NO. DATE <br />FINAL TEST BY: <br />`UAURRATIONDATE:412O123GAUGE#02AC19060031MODEL_MnkOMKS SERVICE RESTORED' YES ❑NO❑ <br />i <br />