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• <br /> Advance Testing & Service Inc <br /> 20 BOX 1485 Everett,WA 98206 Ph:425.3374175 fax:360.6594346 EmaihatsbackfowwaoLcom <br /> BACKFLOWWPREVENTION ASSEMBLY TESTING REPORT <br /> NAME OF PROMS Henry M Jackso ***NEW ASSEMBLY*** Commercial Ca Residential❑ Industrlat❑ <br /> • SERVICE ADDRESS 3302 18th ST ClnEverett ZIP <br /> CONTACT PERSON Brett Mibre Plumbing PHONE( ) FAX( ) <br /> CONTACT COMPANY ADDRESS CITY <br /> LOCATION OF ASSEMBLY <br /> in restroom I`�r`1 g C h Y O p r - i <br /> DOWNSTREAM PROCESS premise DCVA❑ RPBADZI PVBAQ SVGA❑OTHER <br /> NEW INSTALL III EXISTING❑ REPLACEMENT❑ OLD SERIAL# PROPER INSTALLATION?YES( ] NOD <br /> WI MAKE OF ASSEMBLY I 1 k.. ii MODEL Slit- S?ZE 1.0 !i <br /> SERIAL NO, `7 f SI,UI U1 <br /> DCVAIRPBA DCVAIRPBA RPBA PVBAISVBA <br /> INITIAL CHECK VALVE NO.I , VALVE NO.2 � AIR INLET <br /> TEST OPENED AT 7.9. PSID <br /> LEAKED LEAKED <br /> CLOSED TIGHT CLOSEDTIIG' #1 CHECK O. PSID OPENED AT PSID <br /> PASSED g. <br /> FAILED PSID PSID AIR GAP OR4e5 DID NOT OPEN 0 <br /> CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br /> NEW HELD AT PSID <br /> PARTS 0 0 0 0 0 0 LEAKED 0 <br /> AND ❑ 0 , • 0 0 0 0 <br /> REPAIRS 0 0 <br /> 0 0 0 0 CLEANED 0 <br /> ❑ ❑ ❑ o ❑ ❑ REPAIRED 0 <br /> TEST AFTER <br /> REPAIRS LEAKED in LEAKED 0 <br /> CLOSED TIGHT 0 CLOSED TIGHT 0 OPENED AT PSID AIR INLET PSID <br /> PASSED 0 <br /> FAILED 0 PSID PSID SI CHECK PSID CHECK VALVE PSID <br /> AIR GAP INSPECTION;Required minimum air gappseparation provided?Yea 0 No ❑ Detector Meter Reading <br /> REMARKS: <br /> LINE PRESSURE-PSI 8 0 CONFINED SPACE?NO <br /> TESTER'S SIGNATOR IA CERT.NOB4320 DATE 10/27/15 <br /> TESTERS NAME PRINTED;Bradley B Briggs TESTER'S PHONES{425 }117.4I71 <br /> REPAIRED BY: DATE <br /> FINAL TEST BY: CERT NO. DATE <br /> TEST ECU PMEff.MAKMldwest MODELS4S SERIALNOD50404444 , SERVICE RESTORED?TES®NOD <br /> IAI <br /> - <br />