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AACRA Backflow Testing and Re �nc. BACKFLOW PREVENTIO'- 4SSEMBLY TEST REPORT <br />. � (360) 668-1117 <br />WATER PURVEYOR Everett ACCOUIYT <br />ASSEMBLY ID/FILE #/UTILITY DEVICE # Meter # 51191527 <br />NAME OF PREMISE The Towns Commercia! ❑ Residential � <br />SERVICE ADDRESS 11217 19th Ave. SE Everett <br />zIP 98204 <br />CONTACT PERSON Tannon Rocheloau PHONE (425) 766-0208 <br />LOCATION OF ASSEMBLY SE Corner Bldg 11 <br />DOWNSTREAM PROCESS Premise Isolation DCVA 0 RPBA ❑ PVBA ❑ OTHER <br />NEW INSTALL 0 EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLD SER.# <br />APPROVED ASSEMBLY? YES � NO ❑ PROPER IIYSTALLATIOIv? YES ❑v� NO ❑ <br />MAKE OF ASSEMBLY Conbraco/Apollo MODEL DCLF4A sER�AL tvo. 629_655 SIZE 1.25" <br />IIVITIAL DCVA / RPBA DCVA / RPBA RPBA PVBA / SVBA <br />CNECK VALVE NO.1 CHECK VALVE N0.2 AIR INLET <br />TEST OPF,NE� AT_____ ���lf� <br />f:d,�SILi� 'Y�YGIti"f' �1 ��,Q���lt� "�'YC;�f7i' �j OPENED AT PSID <br />PASSED � LEAKED ❑ LEAKED � #1 CHECK PSID <br />FAILED � 1.$ pSID 1,4 AIR GAP OK? DID NOT OPEN � <br />PSID <br />CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br />NEW ❑ � � � � � HELD AT PSID <br />PARTS ❑ ❑ ❑ ❑ � � LEAKED � <br />AND � ❑ ❑ ❑ ❑ ❑ <br />� ❑ ❑ ❑ ❑ ❑ CLEANED � <br />REPAII2S <br />REPAIRED � <br />TEST AFTER CLOSED TIGHT ❑ CLOSED TICHT ❑ RV EXERCISED ❑ <br />REPAIRS AIR INLET PSID <br />LEAKED ❑ LEAKED C7 OPENED AT PSID <br />PASSED � <br />FAILED � PSID PSID #1 CHECK PSID CHK VALVE PSID <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND lsolation valve: Open � Closed ❑ SOV#1 <br />REMARKS: <br />SEPARATIOI�( <br />PASS � FAIL � <br />Open � Closed � SOV#2: Open � Closed � <br />LINE PRESSURE 91 PSI CON�'INED SPACE? NO <br />TESTERS SIGNATURE: �,x��� CERT. No. B5601 DATE 1/22/2016 <br />TESTERS NAME PRINTED Gary L. Brown TESTERS PHONE #_��sO�CCH-'I'I'I7 <br />REPAIRED BY: LIC NO. DATE <br />FINAL TEST BY: __ ________ CERT. NO. n,�,'T'E; <br />CALIBRATION DATE 12-04-2015 GAUCE # 03050953 MODEL Midwest 845 SERVICE RESTORED YES 0 NO ❑ <br />I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. � <br />