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RECEIVE X�USo& -ooz <br /> wBD i �85T�8 ✓ �, Commercial P.o.„ox,z� <br /> BACKFLOW PREVENTION A�SEMBLY �� 2 � ZOf5 Fire Protection Moun�Vcrnon,WA <br /> 1NC. JAz�3 <br /> OPERATICNS cs�o)R�s�cr�a <br /> TEST REPORT MqINTENANCE «0°���'`� <br /> NAME:y�LE t������� /��.� C �(Z (�_U' Q� Pax: (3G0)R1tL107'L <br /> MAILING ADDRESS: <br /> SERVICE ADDRESS: I_I��.2,t�_L_�-V�_�T� ��-L- WA�AC�(� EV E��"`T W A• <br /> �ocArioN:�L_ES�st�� c�r ►�v� l�l��-, � r 1 5�2��4�L�(� �/_Ac� <br /> ��� <br /> �, � <br /> CROSS CONNECTION CONTROL FOR: �NI�TI=—CL (U S�� C- TYPE ASSEMBLY: � _ <br /> A-,- 1 1� ��ry� <br /> MANUFACTURER:�ry_i TS MODEL. �J_Q�]�A 7 QT SIZE: �� SERIAL NO.: v� t�C� <br /> INITIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING <br /> No. 7 Cliock: Closed tight................ ❑ psid No.1 Check: Closetl tighl................ ❑ psid <br /> RPBA Leaked.......................❑ Leaked.......................❑ <br /> OR Reliet Valve Opened.................................. Psid Reliel Valva Opened .................................. psid , <br /> RPpA No.2Chock: Closedtight................❑ No.2Check: Closedtigh[................0 <br /> Leaked.......................❑ Psid Leaked....................... ❑ psid <br /> Passed Test: Yes No _ Passed Test: Yes No <br /> No. 1 Check: Closod Ught................ly �' �.psid No. 1 Check: Closed tighL............... ❑ psid <br /> DCVA Leaked....................... ❑ � /' Laaked....................... O <br /> OR No.2 Check: Closed Gght................� I e �+_psid No.2 Check: Closed tighl................ ❑ _ _psid <br /> DCDA Leaked.......................❑ Leaked....................... ❑ <br /> Passed Tes1: Yes._�__ No Passed Test: Ves No <br /> Air Inlei: Opened psid Air Inlel: Opened psid <br /> Failed to open.........................❑ Failed to open.........................❑ <br /> PVB Check Valve: psid Check Valve: psid <br /> Leaked....................................❑ leaker!....................................❑ <br /> Passod Tes�: Yes No Pnssad Test: Yes__ No <br /> •• . • ' •' <br /> AG Minimum Separa6on: Yes No . � . � . . <br /> ISTHISAPROPERINSTALLATION7 YES� NO CUSTOMERNOTIFIED YES NO <br /> WATER FOUND: ON� OFF ❑ WATER LEFf: ON� OFF � :INE PRESSURE:_ D <br /> Test EquipmenL Make�}'R-O-�`'�i� Modei �sRE�� Serial N �f� Accuracy Verification Date �' 6 <br /> TEST METHOD V v F1' -�CJtY � <br /> REMARKS: <br /> T (� /� �, � LAJ`vT <br /> Ini�ial Tost By: _�—�J L..lLlv���-1 Cert No.�..�(�— Dn�e �"7-U 5 <br /> Tyµd a PMtaG <br /> Repaired By:. _ Dato <br /> RepairTostBy: e o. Date <br /> TypAwP�Med ' <br /> ICERTIFYTHEABOVEREPORTTOBETRUE: Certified� <br /> �� <br /> WHITE COPY(WATER DIV) YELL COPY(C STOMER) PINK COPY(fESTER) <br />