2004 112TH PL SE 2017-01-13 - Laserfiche WebLink

AACRA Backflow Testing and ReF Inc. :.,J.. :v:r�� ,�:,��J� u-�` al'_., ✓��d.�i u �'�e a�iJa,J.L:,J'J�J'� '.:f �.s�� i� �u�u �� u J �� (360) 668-1117 WATER PURVEYOR Everett ACCOUNT # ASSEMBLY ID/FILE #/UTILITY DEVICE # Meter # 53468593 IYAME OF PREMISE The TOwris Commercial ❑ Residential 0 SERVICE ADDRESS 11217 19th Ave. SE Everett ZIP 98204 CONTACT PERSON Tannon Rocheloau PHONE (425) 766-0208 LOCATION OF ASSEMBLY NW Corner Bldg. 15 DOWNSTR�AIVI PROCESS Premise Isolation DCVA [] RPBA ❑ PVF3A [�J �T�-I�Id NEW INSTALL � EXISTING ❑ RGPLACGMGNT ❑ REMOVED ❑ OLD SGR.# APPROVF,D ASSEMBLY? YES �/O NO C1 PROPGR [NSTALLATION? YES � NO ❑ MAKG OF ASSEMBLY Conbraco/Apollo MODEL DCLF4f�1 SERIAL NO. 659032 SI7.E 1.25�� INITIAL DCVA / RPBA DCVA / RPI3A RPBA PVBA / SVBA CHECK VALVE NO.1 CHGCK VALVE N0.2 AIR INLI;T TEST OPENED AT PSID CLOSED TIGHT �❑ CLOSED TICHT � OPENED AT PSID PASSED � LEAKED ❑ LEAKED � #1 CHECK ps� FAILED � 2•0 PSID 1•� PSID AIR GAP OK? DID NOT OPEN � CLEAN REPIACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE NEW ❑ ❑ ❑ � (� � HELD AT PSID PARTS ❑ ❑ ❑ ❑ � � LEAKED � AND ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CLEANED � REPAIRS REPAIRED � TEST AFTER CLOSED TIGHT ❑ CLOSED TIGHT ❑ RV EXEIdCISED ❑ AIR INI.ET p�j� RP',�AIRS �.1�AJKIEY� LJ iLiL+:��tt�;i� I_I OYEN�;ll A7' PSID PASSED � FAILED � PSID PSID #1 CHECK PSID CHK VALVE YSID AIR GAP INSPECTION: SUPPLY PIPE DIAMGTER DETECTOR METER READING LEFT SERV[CE AS FOUND Isolation valve: Open � Closed ❑ SOV#1 REMARKS: TESTERS SICNATURE: �%x��J TESTERS NAME PRINTED Ga�y L. Brown RrPAIRED BY: FINAL TEST BY: SEPARATION PASS � FAIL � Open � Closed ❑ SOV#2: Open � Closed ❑ - LINE PRESSURE 91 PSI CONFINED SPACE? NO CERT. NO. B5601 DATE 1/22/2016 CSTGRS PHONE # (360)668-1117 IC NO. DATE T. N O. DATE CALIBRATION DATE 12-04-2015 CAUGE # 03050953 MODEL Midwest 845 SGRVICF., RESTORED YES d❑ NO ❑ I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.