607 SE EVERETT MALL WAY DIAZ NUTRITION CO 2025-12-01

of forda6�e v/�r��/ PO Box 1255 [N PASS 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.(; BACKROW PREVENTION ASSEMBLY TEST REPORT WATER PURVEYOR Everett ACCOUNT# NAME OF PREMISE Rise Up Nutrition Commercial❑ Residential SERVICE ADDRESS 607 SE Everett Mall Way CITY Everett ZIP 98204 CONTACT PERSON Brandon PHONE(425r308-1704 FAX( ) LOCATION OF ASSEMBLY In front kitchen right of sink DOWNSTREAM PROCESS Ice Machine DCVA O RPBA® PVBA O OTHER NEW INSTALL ® EXISTING ❑ REPLACEMENT❑ REMOVED ❑ OLD SER.# APPROVED DEVICE? YES® NO ❑ PROPER INSTALLATION? YES ® NO ❑ MAKE OF ASSEMBLY Wilkins MODEL 975XL2 SERIAL NO. CFB8211 SIZE 1/2" INITIAL DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA TEST CHECK VALVE NO.1 CHECK VALVE NO.2 AIR INLET OPENED AT 3.2 PSID PASSED ® CLOSED TIGHT ® CLOSED TIGHT® OPENED AT PSID #1 CHECK 8.7 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 O REMARKS: LINE PRESSURE 92 PSI METER NUMBER CONFINED SPACE? No TESTERS SIGNATURE: CERT.NO. B7464 DATE 02-10-25 TESTERS NAME PRINTED: Taro Smithson TESTERS PHONE#( 360}333-2057 REPAIRED BY: DATE FINAL TEST BY: CERT.NO. DATE CALIBRATION DATE 12-12-2024 GAUGE# 12211365 MODEL 845 SERVICE RESTORED? YES® NO❑ I certify that this report is accurate,and I h are used WAC 246-290-490 approved rest methods and rest equipment.