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_� AACRA Backflow Testi�g and Re� ���. �AGKFLOW PREVENTIO►" 4SSEMBLY TEST REPORi <br />(�i80) 668-1117 <br />WATER PURVEYOR Everett ACCOUNT # <br />ASSEMBLY ID/FILE #/UTILITY DEVICE # Meter # 60608904 <br />NAME OF PREMISE The Towns Commercial ❑ Residential ❑�/ <br />SERVICE ADDRESS 11217 19th Ave. SE Everett ZIP 98204 <br />CONTACT PERSON Tannon Rocheloau PHONE ('�25) 766-0208 <br />LOCATION OF ASSEMBLY NE Corner Bld� 16 <br />DOWNSTREAM PROCESS Premise Isolation DCVA � RPBA ❑ PVBA ❑ OTHER <br />NEW INSTALL 0 EXISTING ❑ REPLACEMENT ❑ REMOV�D ❑ OLD SER.# <br />APPROVED ASSEMBLY? YGS I� NO ❑ PROPL�2 INSTALLATION? YES � NO ❑ <br />MAKE OF ASSEMBLY Conbraco/Apollo MODEL DCLF4A SERIAL N�O. 651764 SIZE 1.5" <br />INITIAL DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA <br />CHECK VALVE NO.1 CHECK VALVE N0.2 AIR INLET <br />TEST OPENED AT PSID <br />CLOSED TICHT ❑�/ CLOSED TIGHT � OPENED AT <br />PSID <br />PASSED � LEAKED ❑ LEAKED � #1 CHECK ps� <br />FAIL�D � 1.7 PSID 2•2 PSID <br />AIR GAP OK? DID NOT OPEN � <br />CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE aART CHECK VALVE <br />NEW ❑ ❑ ❑ � � � HELD AT PSID <br />PARTS ❑ ❑ ❑ ❑ � � LEAKED � <br />AND ❑ ❑ ❑ ❑ ❑ ❑ <br />� ❑ ❑ ❑ ❑ ❑ CLEANED � <br />REPAIRS — <br />REPAIRF,D [� <br />"I'EST AFTER CWSED T1GHT ❑ CLOSED TIGHT ❑ RV EXERCiSED ❑ nIR 11vLET i <br />REPAIRS PSID <br />LEAKED ❑ LEAKED ❑ OPENED AT ps� <br />PASSED � <br />FAILED � PS� PSID #1 CHECK PSID CHK VALVE PSID <br />AIR GAP IIVSPECTION: SUPPLY PIPE DIAMETER <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND Isolation valve: Open ❑ Closed � SOV#1 <br />REMARlCS: <br />SEPARATION <br />PASS [] FAIL � <br />Open � Closed ❑ SOV#2: Open � Closed � <br />LINE PRESSURE 90 PSI CONFINED SPACE? NO <br />TESTERS SIGNATURE: ����� CE[tT. �vo. B5601 DATE 1/22/2016 <br />TESTERS NAME PRINTED Gary L. Brown TESTERS PHONE #(360)668-1117 <br />REPAIRED BY: LIC NO. DATE <br />FINAL TEST BY: <br />CALIBRATION DATE 12-04-2015 GAUGE # 03050953 <br />CERT. NO. <br />DATE <br />MODEL Midwest 845 SERVICE RESTORED YES ❑ NO [] <br />I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. <br />% <br />