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�� � AACRA Backflow Testing and Rep �nc. ��'���'"�� �������l�r 1������� T��� �E��R� <br />�r�� '��-�*,.' .-� ' (360) 668-1117 <br />WATER PURVEYOR Everett <br />ASSEMBLY ID/FILE #/UTILITY DEVICG # <br />NAME OF PREMISE The Towns <br />SERVICE ADDRESS 11217 19t�1 Ave. SE <br />ACCOUNT# <br />Meter # 60599865 <br />Commercial ❑ Residential 0 <br />Everett ZIP 98204 <br />CONTACT PERSON Tannon Rocheloau PH01vE (425) 766-0208 <br />LO�CATION OF ASSGMBLY SW Corner Bldg. 12 <br />DOWNSTREAM PROCESS Premise Isolatioll DCVA [] RPt3A L� PVE3A I__1 OTHER <br />NEW INSTALL [� EXISTING U REPLACFMENT ❑ REMOVEU ❑ OLD SGR.# <br />APPROVF,D ASSEMBLY? YCS � NO ❑ PRONER INSTALLATION? YES ❑�/ NO ❑ <br />MAKE OF ASSEMBLY Conbraco/Apollo MODEL DCLF4A SERIAL NO. 659482 SIZE 1.5" <br />INITIAL DCVA / RPBA DCVA / RPBA ItPl3A PVBA / SVBA <br />TEST CHECK VALVE NO.1 CHF,CK VALVE N0.2 ��,ENED A'I' A1R INLET <br />PSIll <br />CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT psj� <br />PASSED � #1 CHECK ps� <br />LEAKED ❑ LEAKED ❑ <br />FAILED 0 O.O p�Ij� 1.$ ps� AIR GAP OK? DID NOT OPEN ❑ <br />CLEAN REPLACE PART CLEAN REPLAC[ PART CLEAN REPLACE PART CHECK VALVE <br />NEW �❑ ❑ �� ❑ ❑ ❑ ❑ HELn AT psrp <br />PARTS ❑ ❑ ❑ ❑ � � LEAK�D ❑ <br />o ❑ ❑ ❑ ❑ ❑ <br />AND � � � � � L_� CLEANED � <br />REPAIRS <br />REPAIRGD ❑ <br />TES'I' AFTER CLOSED TIGHT ❑� CLOSLD T[GHT ❑� RV EX�RCISED ❑ aIR INLET PSID <br />REPAIRS <br />LEAKEll ❑ LEAKED ❑ OPENED AT 1'SID <br />PASSED � � <br />FAILED � 1�6 PSID 1•g PSID #I CHECK PSID CHK VALVE PSID <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPA[ZATION PASS � FAIL � <br />DE'i'ECTOR METGR READING <br />LEFT SERVICE AS FOUND �solation valve: Open �� Closed ❑ SOV#1 Open �/❑ Closed ❑ SOV#2• Open � Closed ❑ <br />REMARKS: <br />TESTERS SIGNATURE: �%��� <br />TESTERS NAME PRINTED �ary L. Brown <br />�tEPAIR�D BY: Gary L, Brown <br />FINAL TCST BY: Gary L. Brown <br />- LINE P1dESSURE 90 PSI CONFINED SPACE? Na <br />CERT. N�. ��601 DATE 1/22120'i6 <br />TESTGR� PHOI�IG # (360)668-1117 <br />�[C No. BROWNGL909Q pAT� 01-22-2016 <br />cr�zT. �ro. ��601 DA��� 01-22-2016 <br />CALIBRATION DATE 12-04-2015 CAUC:E # 03050953 MODEL Midwest i345 SERVICG RESTORCD 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. �j� <br />✓ <br />