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Compu�er ID M _ <br /> CiTY OF EVERETT PUSLlC YORKS <br /> 3200 Cedar St. <br /> BACKFLOW PREVENTION ASSEMBL1f Eve�^estt, WA 98201 <br /> TEST REPORT <br /> �. RETURN NO LATEN T1111N_ <br /> P�!C K D oneer�ech�d-monds,NA <br /> NAME OF PREMISES <br /> �PqE55�Affti�• GAS STATION COr�T�CT PERSO►� Oerek Anderson- 425 640 8282 <br /> SERVICE ADORES,S 425 Mest Caalno Road, Everett. NA 982 <br /> LOCATION OF ASSEMBLV � e ' � ' Q <br /> z I'r l � � <br /> ASSEMOLY , K�crur+cn .�oon s�i sr�wuno <br /> a p �e� 0 <br /> LINE PRESSUFiE A7 TIME OF TEST LBS. TYPE OF ASSEMBLV� <br /> p�Auc�d Vrenun Auemblkf �����^��� <br /> DaRN Clwcli�s�m�EW� Nelkl AM MMN f.'Me�YMw <br /> 1�ICMeM 7ndLhec� Vslv! OpnMA�1 <br /> Ps4 O�d <br /> �,� ��M� Cbua�yM 00��1�M Otl ne1 apr� 0 4M�d � <br /> Tesl ���� � UMM �Lll Dsb <br /> UM�d U ��� iJ <br /> i <br /> � <br /> Il�paxs <br /> •M <br /> MAIdW�S • <br /> UseE <br /> �CSI AilO� OC�cbsed IqM LI CbzM Iqh� :J Ope�rd al �"��� <br /> flt�ax <br /> liP._`Md ___Osb P� 0� <br /> AIR GAP INSEPCTION: Required minimu a+gap seperalion povided•••�es 7 No O <br /> fiEMAfiKS: C � /t-h-�7����`i�L�b f �A <br /> � � �� <br /> � —, —"�J <br /> j ( I � K h�� � ��-� �'° � � � OI'� ���.�G�� <br /> , e � e �' �ov ►� �9 , ;� � <br /> I b <br /> THE A80VE REPORi IS CERTIPIED TO BE TqUE: <br /> INITIAL TESi PERfORMED GV _ CERT.NO. BAT OB�� — �� �haGy-�fy � <br /> / ( <br /> REPAIREDBY __ — �� <br /> FMlAL 7EST PERFORMEO BV ��T•�• �� <br />