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AACRA Backflow Testing and Repair, �nc. BA�KFLOW PREVENTION ASSEMBLY TEST REPORT <br />(360) G68-1117 <br />WATER PURVEYOR Everett ACCOUNT # <br />ASSEMBLY ID/FILE #/UTILITY DEVICE # Meter # 60608903 <br />NAME OF PREMISE The Towns Commercial ❑ Residential � <br />SERVICE ADDRESS 1 1217 19th Ave. SE Everett ZIP 98204 <br />CONTACT PERSON Tannon Rocheloau PHONE (425) 766-0208 <br />LOCATION OF ASSEMBLY North Side Center of Bldg. 1 <br />DOWNSTREAM 1'ROCESS Doinestic Water DCVA [] RPBA ❑ PVI3A ❑ OTHER <br />NEW INSTALL � i:XISTING ❑ REPLACF,MENT ❑ RGMOVED ❑ OLD SER.# <br />APPROVI;D ASSEMBLY? YCS � NO ❑ PROPER INSTALLATION? YES �] NO ❑ <br />MAKE OF ASSEMBLY Conbraco/Apollo M011GL UCLr4A SERIAL 1Y0. 660743 SIZE 2�� <br />I1�Tj�,IA�. DCVA / RPBA llCVA / RPBA RPBA PVBA / SVBA <br />CHECK VALVE NO.I CHECK VALVE N0.2 AIR INLET <br />TEST OPENED AT PSID <br />CLOSED TIGHT � CLOSED TIGHT 0 OPENED AT PSID <br />PASSED ❑� LEAKED ❑ LEAKED � #1 CHECK PSID <br />FAILED � 2.2 PSID 2•� PSID <br />AIR GAP OK? DID NOT OPEN ❑ <br />CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br />�v�rw n n -- - _------ n n -- ------ � � --------- HE�.n AT _ ___�.__._ . __ �s� <br />PARTS L� ❑ ❑ ❑ U � LEAKED � <br />AND � � � � � � <br />❑ ❑ ❑ ❑ ❑ ❑ CLEANED � <br />REPAIRS <br />REPAIRED � <br />TEST AF'TGR CLOSGD TIGHT ❑ CLOSED TIGHT ❑ RV EXERCISED C] AIR INLET PSID <br />REPAIRS <br />LEAKTD ❑ LEAKEll ❑ opENEu AT PSID <br />PASSED � <br />PSID PSID #1 CHECK PSID CHK VALVE PSID <br />FAILED � <br />AIR GAP INSPECTION: SUPPLY PIPE DIAMETER SEPARATION PASS � FAIL � <br />DETECTOR METER READING <br />LEFT SERVICE AS FOUND Isolation vah�e: Open 0 Closed ❑ SOV#l: Open d❑ Closed ❑ SOV#2: Open ❑d Closed ❑ <br />REMARKS: <br />LINE PRESSURE 99 PSI CONFINED SPACE? No <br />TESTERS SIGNATURE: ����� CERT, NO. g5601 DATE 4/20/2016 <br />TESTERS NAME PRINT�D Gary L. Brown TrSTGRS PHONE #(360)668-1117 <br />REPAIRED BY: LIC NO. DATE <br />FINAL TEST BY: CERT. NO. DATE <br />CALIBRATION DATE 12-04-2015 GAUCE # 03050953 MOD�L Midwest 845 SERVECF. 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. n� <br />U� <br />✓ <br />