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BACKFLOW ASSEMBLY TEST REPORT <br />13ATrna n Testi nc1,N <br />BACKFLOW ASSEMBLY TESTING AND REPAIR <br />46Tp,ER / FApUT WE <br />WNTALT /OWNER WE <br />WATEA w9VEYd1 <br />The Reserve at Everett LIIi <br />EVERETT PUBLIC WORKS <br />NEW WNSTNUEIION ASSINBLY/WSTOMER IDF <br />PNONE NUMBFA fA%NUMBDL <br />wRVEYOR ODxTILTNWE <br />®Y ❑N Meter# I852344091 <br />Tim Markham <br />SERVICE ADDRESS/METER NVMBER <br />QbTOMER/OWMaE/WHTAR MAUMG ADOIIFSS <br />PJRVEYOR FAX NUMBER <br />8920 Evergreen Way <br />425 257-8882 <br />(EY/STATE <br />aP WOE <br />(aY/STATE <br />aP(EIOE <br />wRVEYOR EMAIL AECRESi <br />Everett WA <br />98208- <br />tmarkham@everettwa.gov <br />ASS(EIBLY MAMUFACTINFA <br />MODEL <br />SERIAL MRABER <br />T9E <br />Siff <br />pPNNSTpFAII ROQs <br />AM-' <br />2000BM3 <br />35094 <br />DCVA <br />3/4" <br />FIRE SPRINKLER BYPASS <br />LOCATION OF ASSEMBLY <br />Riser room at NE comer of buildingDYES <br />WNFIHED SPACE <br />®NO <br />INSTALLATION TYPE PRFVIOLLS HAIR /MODFl / SnE / SERIAL MINBER <br />DETECTOR READ <br />®New []Existing ❑ Replacement <br />N/A <br />0011MNIOV[D ASSEMBLY (SIFT IDE LLST)I <br />® YES ❑ NO <br />OMENTAnON <br />H <br />FROIER IXSTALUnOX <br />® YES ❑ NO <br />PRFS9IRE <br />WARA UN'PSG <br />80 PSIG <br />VALVE POSn10HSPRIOR TO nsm1G <br />SOV#1 ®ON ❑OFF SOV#2 ®ON ❑OFF <br />INITIAL TEST RESULTS <br />TEST AFTER REPAIRS/CLEANING <br />CHECK VALVE#1 CLOSED TIGHT ❑ <br />CHECK VALVE#I CLOSED TIGHT ❑ <br />LEAKED ❑ <br />LEAKED ❑ <br />RELIEF VALVE OPENED AT PSID <br />RELIEF VALVE OPENED AT PSID <br />FAILED TO OPEN ❑ <br />FAILED TO OPEN ❑ <br />CHECK VALVE#2 CLOSED TIGHT ❑ <br />CHECK VALVE #2 CLOSED TIGHT ❑ <br />RPBA <br />LEAKED ❑ <br />LEAKED ❑ <br />ACTUAL PRESSURE DROP <br />PSID <br />ACTUAL PRESSURE DROP <br />PSID <br />ACROSS CHECK VALVE#I <br />ACROSS CHECK VALVE #1 <br />PASSED TEST ❑YES ❑NO <br />PASSED TEST ❑YES ❑NO <br />CLEAN / REPAIR: ❑ see remarks <br />APPROVED AIR GAP []YES ❑NO <br />APPROVED AIR GAP ❑YES []NO <br />CHECK VALVE#1 CLOSED TIGHT 2.1 PSID <br />CHECK VALVE#1 CLOSED TIGHT PSID <br />LEAKED ❑ <br />LEAKED ❑ <br />DCVA <br />CHECK VALVE#2 CLOSED TIGHT 2.1 PSID <br />CHECK VALVE 02 CLOSED TIGHT PSID <br />LEAKED ❑ <br />LEAKED ❑ <br />PASSED TEST ®YES ONO <br />PASSED TEST ❑YES []NO <br />CLEAN / REPAIR: ❑ see remarks <br />PEMARAS <br />VALVE IOS MAFTER TESTING <br />SOV41 ®ON ❑OFF SOV#2 ®ON []OFF <br />1FSTFA NW[ <br />"I �InnfAnoN <br />TEST GAINi MAIR <br />GAUGExWfE <br />TEST fA1XE SERIAL NUMBER <br />CAUfi EALLBM TION DATE <br />Jason A. Moe <br />B4536 <br />Mid -West <br />845-5 <br />03051790 <br />01/08/2015 <br />REPADROBY <br />C0TIPANYNWE <br />PHONE MUMUR <br />N/A <br />FLVALTESTBY <br />RATCERF1=011 <br />TESTEJAIfk MAR <br />CADGE MODEL <br />WNPAMYNWE <br />PMONE NUMBER <br />N/A <br />BATman Testing <br />206 229-1618 <br />art of nNu TFSi <br />05/13/2015 <br />SIGNAT <br />(1 EREDY CERTIFY THAT E USED WAC 246290-990 AGPROVED, USC ID°i EdMon TEST METHODS AND DIFFERENTIAL PRESSURE TEST EQU!RMEEfr PoR 111E ABOVE TEST ULTS) <br />(I H <br />BIZ <br />