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After the Initiai TestlCertification, all <br />Annual Test Results should be sent to: <br />XIUG�I-0G> <br />Backilow Prevention Assembly Test Report � <br />Mailing Address n � Tester Informatfon: <br />Company W�fi'1 CUAsi �I /lo('• ��lAf� B.A.T.MASTER <br />Address <br />Ciry <br />Phone �U�✓ ��v' ,�� J ` g� � <br />Service Address <br />Company,���NTic,L�SrAN,4/�IE,c�v3N f�d���% Manulacturer �/�!-� <br />Address �9 `�� � � ��V �r� M�� ��'YModel ��� Q � <br />City �1/ �'-��l Type �'� �b� <br />Phone Size ' � <br />Perm?t Number Location L,�,�O� �j]�C,- 5rip/� nc_�A. �NAr"� ccN�*%t�- <br />Serial # <br />BackflowService.net <br />2918 Cavalero Road <br />EvereH, WA 98205 <br />(425) 210-9866 <br />2 <br />Reduced Pressure Princip�le Assembly <br />Double Check Valve Assembly <br />Check Valve #1 Check Valve #2 <br />Leaked ❑ Leaked ❑ <br />IniBal Closed Tight a�' Closed Tight �" <br />Test ��- � <br />Held at_�21C.2_PSID Held at��PSID <br />Repairs <br />Details <br />Final <br />Test <br />Cleaned ❑ <br />Replaced ❑ <br />Closed Tight ❑ <br />Cleaned ❑ <br />Replaced ❑ <br />Closed Tight ❑ <br />Relief Valve <br />Did not Open ❑ <br />)penedat ✓AQ PSID <br />Cleaned ❑ <br />Replaced ❑ <br />Line <br />Make <br />Model <br />S/N <br />Size <br />Fire Line <br />Make <br />Model <br />S/N _ <br />Size _ <br />Make <br />Model <br />S/N _ <br />Held a� PSID Held at PSID Opened at PSID <br />Size <br />Comments: <br />Si Meter Reading — Test Kit Model �� <br />7 — Meter Number Kit S/N d � 7 <br />��J� % Lri,�p�f Calibrated Date � Z Z � <br />i State License <br />RPDA <br />The above report is certitied to be true. <br />DatefTime Tester(Prin1 <br />�� <br />Repairs <br />Final <br />rniHrEo ir� n�E u.s A <br />Tester # <br />Vehicle # <br />Passed Failed <br />.r�, u <br />❑ ❑ <br />❑ ❑ <br />p,�:ro;,:,�o��.�wm, �, �� <br />