2006 112TH PL SE 2017-01-13 - Laserfiche WebLink

AACRA Backflow Testing and Re� r � (360) 668-1117 WATER PURVEYOR Everett nc. BACKFLOW PREVENTIO �SSEMBLY TEST REPORT ACCOUNT# ASSEMBLY ID/FILE #/UTILITY DEVICE # Meter # 53468593 NAME OF PREMISE The Towns Commercial ❑ Residential 0 SERVICE ADDRESS 11217 19th Ave. SE Everett ZIP 98204 CONTACT PERSON Tannon Rocheloau PHONE (425) 766-0208 LOCATIOIV OF ASSEMBLY NW Corner Bldg. 15 DOWNSTREAM PROCESS Premise Isolation DCVA [� RPBA ❑ PVBA ❑ OTHER NEW INSTALL ❑d EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLD SER.# APPROVED ASSEMBLY? YES ❑�/ NO ❑ PROPER INSTALLATION? YES � NO ❑ MAKE OF ASSEMBLY Conbraco/Apollo MODEL UCLF4A SERIAL NO. 659032 SIZE 1.25�� INITIAL DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA CHECK VALVE NO.I CHECK VALVE 1�10.2 AIR [NLET TEST OPENED AT PSID CLOSED TIGHT ❑�/ CLOSED TIGHT �❑ OPENED AT PSID PASSED �❑ LEAKED ❑ LEAKED � #� C��EC[c PSID D1D NOT OPEN ❑ FAILED � 2.0 PSID I•� PSID AIR GAP OK? CLEAN REPIACE PART CIEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE NEW ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID PARTS ❑ ❑ ❑ ❑ � � LEAKED � ❑ ❑ ❑ ❑ ❑ ❑ `�D ❑ ❑ ❑ ❑ ❑ ❑ CLEANED ❑ REPAIRS REPAIRED � TEST AFTER CLOSED TIGHT ❑ CLOSED TIGHT ❑ RV EXERCISED ❑ AIR INLET PSID REPAIRS LEAKED O LEAKED ❑ OPENED .4T PSID PASSED � FAILED � PSID PSID #1 CHECK PSID CHK VALVE PSID AIRGAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION PASS� FAIL� DETECTOR METER READINC LEFT SERVICE AS FOUND �solation valve: Open � Closed ❑ SOV#1 Open � Closed ❑ SOV#2: Open � Closed ❑ REMARKS: TESTERS SICNATURE: �%x�� TESTERS NAME PRINTED Gary L. Brown REPAIRED BY: FINAL TEST BY: - LINE PRESSURE 91 PSI CONFINED SPACE? No CERT. NO. B5601 DATE 1/22/2016 TESTLRS PHONE # (360)668-1117 LIC IYO. DATE CERT. NO. DATE CALIBRATIOIY 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.