2015 113TH PL SE 2017-01-13 - Laserfiche WebLink

AACRA Backflow Testing and Repair, ��c. BACKFLOW PREVENTION ASSEMBLY TEST REPORT • (360) 668-1117 WATER PURVEYOR Everett ACCOUNT # ASSEMBLY ID/FILE #/UTILITY DEVlCE # Meter # 60608907 NAME OF PREMISE The Towns Commercial ❑ Residential � SERVICE ADDRESS 11217 19th Ave. SE Everett ZIP 98204 CONTACT PERSON Tannon Rocheloau PHOf�E (425) 766-0208 LOCATION OF ASSEMBLY SW Corner Bldg 2 DOWNSTREAM PROCESS Domestic Water DCVA � RPBA LJ PVBA IJ OTHEK NEW INSTALL � EXISTING ❑ REPLACEMENT ❑ REMOVED ❑ OLD SER.# APPROVED ASSEMBLY? YES Cl NO ❑ PROPER INSTALLATION? YES � NO ❑ MAKE OF ASSEMBLY Conbraco/Apollo MODEL DCLF4A SERIAL NO. 6gg224 SIZE 2�` DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA INITIAL CI-€ECK VALVE NO.1 CHECK VALVE N0.2 AIR INLET TEST OPENED AT PSID CLOSED TIGHT ❑�/ CLOSED TIGHT � OPENED AT PSID PASSED 0 #1 CHECK PSID LEAKED ❑ LEAKED � DID NOT OPEN ❑ FAILED � 1.9 pgID 1 g ps� AJR GAP OK? CLEAf� REPLACE PART CL[AN REPLFlCE PART CLE�N REPLACE PART CHECK VALVE NEW ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID PARTS ❑ ❑ ❑ ❑ � � LEAKED ❑ ❑ ❑ ❑ ❑ ❑ ❑ AND � � � � � � CLEANED ❑ REPAIRS REPAIRED ❑ TEST AFTER CLOSED TIGHT ❑ CLOSED TIGHT ❑ RV EXERCISED ❑ AIR INLET PSID REPAIRS LEAKED ❑ LEAKED ❑ OPENED AT ps� PASSED � PSID PSID #1 CHECK PSID CHK VALVE PSID FAII.�I) � AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION rws� U r�►iL U DETECTOR METER READING LEFT SERVICE AS FOUND Isolation valve: Open � Closed ❑ SOV#l: Open 0 Closed ❑ SOV#2: Open ❑d Closed ❑ REMARKS: LINE PRESSURE 9O PSI CONFINED SPACE? No TESTERS SIGNATURE: �x�� CERT. NO. B5601 DATE 4/20/2016 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 accura[e, and I have used 64'!tC 246-290-490 approved test methods and test equipment. �I7