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� eaacA.ow�snr�c �C /la°t-ad`� <br /> &SERYICE, INC <br /> 425-334-3350 <br /> B4CKFLOW PREVENTION ASSEMBLY TEST REPORT <br /> ACCOUNT# <br /> NAME OE PREMISE �f�l�l � A`t ���A'i��N� Commercl�ba- Raideatlrl❑ <br /> SERVICE ADDRESS I Z.O-s G�2/�-f=!SL�f/I lRU CITY��� Z�p�d I , <br /> CONTACT PERSON PHONE( ) F�� � <br /> LOCATIONOFASSEMBLY I���� �Z� �'Q�L% lC:.l� l/1.liY}.l�.e�l4 , <br /> DOWNSTREAM PIiOCESS��' �� //U/�'1��� 1�VA ❑ RPBA J� PVBA ❑ OTHER <br /> NF.W INSTALL� EXISTING O REPLACEMEIVT 0 OLD SER.# PROPER INSTALLATION7 YES P.�NO❑ <br /> MAKE OF ASSEMBLY �A l7-5 MODEL �D q QT� SEWAL NO. <br /> �3Sz 7b y S�ZE� <br /> nc'VA/RRBA DCVA I RPBA $�� PVBAlSVBA <br /> INITIAL ru�rK VAL•V�0.1 ,c�HFrK VALVE N0.2 AIR INLET <br /> TEST OPENED AT�PSID <br /> OPENED AT PSID <br /> LEAKED ❑ LEAKED ❑ �� CHECK�PSID <br /> DID NOT OPEN ❑ <br /> PASSED � ps�p PSID A�R GAP OKT�� <br /> FAILED 0 ' <br /> [LEAN REPLACF. PART CLEAN REPIACE PAiIT CLHAN NEPUCO PMT C}�CKVALVE <br /> HELD AT PSID <br /> PARTS � � ❑ ❑ ❑ ❑ LEAKED 0 <br /> AND � � <br /> REPAIRS � � � � � � CLEANED ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ REPAIRED ❑ <br /> TEST AFTER OPBNED AT PSID AIR MLET PSID <br /> REPAIRS LEAKED O LEAKED ❑ <br /> PASSED ❑ '� PS1D PSID �� CHECK PSID CHK VALVE PSID <br /> FAILED ❑ <br /> AIR GAP INSPECT[ON:Requlred minimum eir gap sepvation provided4 Yes,.l9 No O Detettor Meter Rading <br /> LINE PRESSURE G� PS1 <br /> REMARKS: <br /> WSDOH APPROV DEVICE? YES�NO❑ CONRINED 9PACE? ti'" <br /> TESTERS SIGNATURE: �'�--�RT.NO. 0461 DATE l�"8�ll <br /> TESTERS NAME PRINTED: Thomas Wnhlman TESTERS PHONE# 2(,_06 ) 255-9646 <br /> • DATE <br /> REPAIRED BY: <br /> FINAL TEST BY: CERT.NO. DATE�_ <br /> CALIBRATION DATE 07 /06 /)� GAUGE N 357357 MODEL �SERVICE RESTORED? YES� NO❑ <br /> �� 1 cntffy 1hM�Ak npnHls accurwe.and/hmY usrd WAC11b190d 90 approved4af nrlAsdr oud taf qrlpMre[ <br />