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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />UOMINICS.M�LAUGHUN ��ULOi/S UG� GREATERSEATTLEAREA&PENINSULA <br />STATE CER'['IFIED PHONE: (360)598-44�5 <br />INDEPENDENT OPERATOR FAX: (360)598-4456 <br />CELL: (206)890-8337 <br />'I'OLL FREE: (866)897-4445 <br />ACCOUNTa _ . <br />NAME OF PREMISE <br />SERVICE ADDRFSS <br />COM'ACT PERSON <br />LOCATIGN OF ASSEMBLY <br />DOWNSTREAM PROCESS _ <br />PHONE( ) <br />NEW QdSfALL ❑ EXISTING ❑ REPLACEMENT � OLD SER. H <br />Commercial ❑ Resideatial ❑ <br />CfI1' 21P <br />FAX ( ) <br />DCVA ❑ RPBA ❑ PVBA O OTNER <br />MAKE OF ASSEMBLY MODEL SERIAL NO. <br />PROPER INSTALLA770N? VFS � NO O <br />. pCVA/RPUA DCVA/RPBA RPBA PyBA/SVHA <br />INITIAL CHECK VALVE iVp.t CHECK VALVE N0.2 f�IR INLfi7' <br />TEST OPENED AT PSTD <br />CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT PSm <br />LEAKED ❑ LEAKED O #I CFIECK PSm <br />PASSED O DID NOT OPEN � <br />FAILED Q PSID PSID AIIt GAP OK? <br />c�,w aeruce enier c�.cu+ nse�.ncs r.uu c�ctiv ureuce ener CfIECK VAI,VE <br />NIF,W ❑ ❑ ❑ ❑ ❑ O HELD AT PSm <br />PARTS ❑ ❑ ❑ ❑ ❑ ❑ LEAKEU ❑ <br />AND ❑ ❑ ❑ ❑ ❑ ❑ <br />REPAIRS CLEANED � <br />❑ ❑ ❑ ❑ ❑ ❑ <br />REPAIRED ❑ <br />TEST AFfER CLOSED TIGHT ❑ CLOSED TIGHT ❑ <br />�P�� LEAKED ❑ LEAKED ❑ OPENED AT PSID AIR INLET PS[D <br />PASSED ❑ pg� ps� Nl CHECK PSID CHK VALVE PSID <br />FAILED ❑ <br />AIR GAP [NSFECTION: Ccquirod minimwo nir gep scpnr000n pro�idod9 Yes ❑ No ❑ Dtlector Meter Reading <br />REMARKS: <br />TESTERS SIGNATURE: <br />TESTERS NAME PRINTED: <br />DOMINIC S. MCLAUCHLIN <br />LINE PRESSURE <br />CONFINED SPACE? <br />CERT. NO. dAT 4253 <br />1'ESTERS PFiONE k ( �60 ) <br />'1'E <br />598-4445 <br />REPAIRED BY: L[C NO MCLAUD5960JE DATE <br />PSI <br />FINAL 7'EST BY: I;ERT. NO. DA7'E <br />1I0309R6 MIDWEST <br />CALfIIRATION DA'fE _/_ /_ GAUGE q 10040661 MODEL A30 SERVICE FOUND ON ❑ OFF ❑ <br />00793 H'ATTS SERVICE RESTORED° YES ❑ NO ❑ <br />00775 TK99U <br />f con�y rhat rhis r(pon u accwate, and! Mre used WAC SIbI90-f 90 oppro.�<d resr m�ihad, and urt aquipinru <br />