1903 112TH PL SE 2017-01-13 - Laserfiche WebLink

AACRA Backflow Testing and Re• �nc. BACKFLOW PREVENT10�4SSEMBLY TEST REPORT (360) 668-1117 WATER PURVEYOR Everett ASSEMBLY ID/FILE #/UTILITY DEVICE # NAME OF PREMISE The Towns SERV[CE ADDRESS 11217 19th Ave. SE ACCOUNT # Meter # 51191527 .Commercial ❑ Residential ❑d Everett ZIP 98204 CONTACT PERSON Tannon Rocheloau PHONE (425) 766-0208 LOCATION OF ASSEMBLY SE Corner Bldg 11 DOWNSTREAM PROCESS Premise Isolation DCVA � RPBA ❑ PVBA ❑ OTHER NEW INSTALL ❑�/ EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLD SER.# APPROVED ASSEMBLY? YES ❑�/ NO ❑ PROPER iNSTALLATION? YES ❑d NO ❑ MAKE OF ASSEMBLY Conbraco/Apollo MODEL DCLF4A sER�AL No. 629655 SIZE 1.25'� INITIAL DCVA / RPBA DCVA / RPBA RPBA PVBA / SVBA CHECK VALVE IVO.1 CHECK VALVE N0.2 AIR INLET TEST OPENED AT PSID CLOSED TIGHT CJ CLOSED TIGHT ❑� OPENED AT PSID PASSED ❑� LEAKED � LEAKED � #1 CHECK PSID FAILED � I.H PSID 1•4 PSID AIR GAP OK? DID NOT OPEN � CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE NEVV ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID PARTS ❑ ❑ ❑ ❑ � � LEAKED � AND O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CLEANED � REPAIRS REPAIRED � TEST AFTER CLOSED TIGHT ❑ CLOSED TIGHT ❑ RV EXERCISED ❑ AIR 1NLET ps� REPAIRS LEAKED ❑ LEAKED ❑ OPENED AT PSID PASSED � FAILED � PSID PSID #1 CHECK PSID CHK VALVE PSID AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATIOIv PASS� FAIL� DETECTOR METER READING LEFT SERVICE AS FOUND Isolation valve: Open ❑d Closed ❑ SOV#1 Open [] Closed ❑ SOV#2• Open � Closed ❑ REMARKS: LINE PRESSURE 91 PSI CONFINED SPACE? No TESTERS SICNATURE: �x�� CERT. NO. g5601 DATE 1/22/2016 TESTERS NAME PRINTED Gary L. Brown TESTERS PHONE #(360)668-1117 REPAIRED BY: LiC NO. DATE FINAL TEST BY: CERT. NO. DATE CALIBRATION DATE 12-04-2015 GAUGE # 03050953 MODEL Midwest 845 SERVICE RESTORED YES � NO ❑ I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. ��