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Advance Testing & Service Inc <br /> PO BOX 1485 Everett,WA 98246 Ph:425.3314115 Fax 36 04594346 Email atsbackflow@aoLcom <br /> BACKFLOW PREVENTION ASSEMBLY TESTING REPORT <br /> NAME of PREMISE Henry M Jacks ***NEW ASSEMBLY*** Commercial pg Residentlat❑ Industrial❑ <br /> SERVICE ADDRESS 3302 18th ST ITT, ZIP <br /> zIP <br /> CONTACT PERSON Brett Mibre Plumbing PHONE( ) FAx t ) <br /> CONTACT COMPANY ADDRESS CITY <br /> LOCATION OF ASSEMBLY <br /> in restroom P c k r 00 r�'1 <br /> DOWNSTREAM PROCESS Premise DCVA❑ RPBAti. PVBA❑ SVBAD OTHER <br /> NEW INSTALL EXISTIIN1G❑ REPLACEMENT OLD SERIAL# PROPER INSTALLATION?YES`'INOD <br /> W <br /> MAKE OF ASSEMBLY 1 \�.�VIS MODEL 3 17S!( t_SIZE 1.0 SERIAL NO. /1U S r/O o <br /> DCVAIRPBA DCVAIRPBA RPBA PVBAISVBA <br /> INITIAL CHECK VALVE NO.I CHECK VALVE NO.2 AIR INLET <br /> TEST OPENED AT Y:?PSID <br /> LEAKED ❑ LEAKED 0 <br /> CLOSED TIGHT r. CLOSEDTIGHTt #1 CHECK /L ID OPENED AT PSID <br /> PASSED g <br /> FAILED PSID PSID AIR GAP OK7.yGS 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 LEAKED 0 <br /> AND ❑ 0 0 0 0 0 <br /> REPAIRS 0 0 0 0 0 0 , , CLEANED 0 <br /> ❑ ❑ <br /> in ❑ ❑ In REPAIRED Q <br /> TEST AFTER <br /> REPAIRS LEAKED 0 LEAKED 0 <br /> CLOSED TIGHT 0 CLOSED TIGHT 0 OPENED AT PSID AIR INLET PSID <br /> PASSED ❑ <br /> FAILED ❑ PSID PSID #t CHECK PSID CHECKVALVE PSID <br /> AIR GAP INSPECTION:Required minimum air gap separation pro ided?Yes 0 No 0 Detector Meter Reading <br /> REMARKS: Lde/ / / <br /> UNE PRESSURE-PSI bV CONFINED SPACE?NO _ <br /> TESTER'S=NaTUR��pOd <br /> CERT.No 32(1DATE 10/27/15 <br /> TESTER'S NAME PRINTED:Bradley B g*5 TESTER'S PHONE# 425 } 117.4175 <br /> REPAIRED SY: DATE <br /> FINAL TEST BY: CERT.NO. DATE <br /> TESTEOUIPMENT-MAKEMtdWeSt MODEL/WS SERIAL N0050404444 . SERVICERESTORED?YES®NO❑ <br />