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After the Initlal 7esUCertification, all <br />Annual Test Results should be sent to: � ����- G�� <br />Backflow Prevention Assembly Test Report <br />Matling Address � � , _Tester Information: <br />Company <br />Add�ess <br />Cil�y <br />Phone �JCUN �� .�,5� �� 20 <br />B.A.T.MAS7ER <br />BackflowService.net <br />2918 Cavalero Road <br />Everett, WA 98205 <br />(425) 210-9866 <br />Service Address Serial # X ���i <br />Companyl�tL7J{�(j�� ASiAN �4MF,/LCAN 6U�j Manulacturer- �'�%1�!�� <br />Address �%% sG �✓����� �/✓y� Model '70 �l 30Z <br />City �U�� TYPe f�P�A <br />Phone ��� <br />Size . � <br />Permit Num6er <br />Initial <br />Test <br />Repairs <br />Details <br />Final <br />Test <br />Reduced Pressure Princi <br />Double Check Valve Assembly <br />Check Valve #1 Check Valve #2 <br />Leaked Leaked ❑ <br />Closed Tight ❑ Closed Tight ❑ <br />Held at PSID <br />Cleaned � <br />Replaced <br />Closed Tight .� <br />Held at � �C PSID <br />Comments:��n = �.1pS , <br />—T <br />�7,��j= `.7ti`�•'crrv9-i'�'/Z <br />�,�,� o%/'� L�i,�!fU� <br />The above report is certified to be true. <br />Datelfime Tester(Prin1 <br />INtiai , <br />Test ,� � G <br />Repairs �� ff <br />Final �� �� <br />PP�MEOINTMEV$A. <br />Held at PSID <br />Cleaned � <br />Replaced ❑ <br />Closed Tight � <br />Hetd at�% PSID <br />Location �t iZ� iAC� ISP f/NQF�L f�uNf�,P� <br />le Assembly <br />Relief Valve <br />Did not Open ❑ <br />7pened at PSID <br />Cleaned ❑ <br />Replaced ❑ <br />Opened at �'/ PSID <br />Make <br />Model <br />S/N _ <br />Size _ <br />Make <br />Model <br />S/N _ <br />Size _ <br />Make <br />Model <br />S/N _ <br />Size _ <br />Line <br />RPDA <br />Assem <br />Meter Reading Test Kit �vlodel �� <br />Meter Number Kit S/N '� y� <br />Calibrated Date � � <br />State License <br />� Vehicle # _ <br />Tester # <br />ct <br />G'1 <br />Passed Faiied <br />u Y� <br />a ❑ <br />�`-� <br />PTt^ORu� 0 ��O+IaY rt cvn <br />