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A a A liv� 'A oviia-V <br />BACKFLOW PRE .I F": T ION ASSEMBLY TEST REPORT <br />NAME OF PREAUSE: <br />Commercial R Residential �. <br />SERVICEADDRESS: j13� Arn55q�1 St CIT)': F.IPfzll ZIP: 98.2 01 <br />CONTACT PERSON: <br />PHONE: ( <br />LOCATION OF ASSEMBL 3: OV lFnsA ��►f F 71t���15 G1_1(111 <br />r•.4.r: ( <br />DOWNSTREAM PROCESS: A%A'ildin2 Math -Plumbing DCVA: ❑ RPBA:9 Pi BA: ❑ OTHER: <br />NEIV INSTALL: X EXISTING: ❑ REPLACEMENT.• ❑ OLD SER. # PROPER INSTALLATIOAT YES g NO ❑ <br />A1,4KEOFASSEAfBL)'r lr %A' -i AfODEL: 6O9A4RCXT,VERLIL ,VO.: 252388 SIZE: 2 <br />4t <br />DCVA / RPRA <br />DCVA / RPRA <br />RPBA <br />PIWA / .SI'HA <br />INITIAL <br />CHECK VALVENO. 1 <br />AIR INLET VALVE <br />CHECK V4LIX NO. I <br />OPEn'ED.4T � PSID <br />TEST <br />CLOSED TIGIIT S <br />CLOSED TIGHT 5Z <br />OPENED A7' PSID <br />LEAKED ❑ <br />LEAKED ❑ <br />#I CHECK_70 PSID <br />PASSED $ <br />DID n'OT OPEN' ❑ <br />FAILED❑ <br />7 PSID7 Ps <br />PSID <br />AIRGAPOK? Yes <br />cIZ4N REPt_a'e P4Rr <br />ccEAny REPLACE PART <br />a.Lcv REP64CE FIRr <br />CHECK I'ALVE <br />NEW <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />HELD AT PSID <br />PARTS <br />❑ ❑ <br />❑ El <br />ElLEAKED <br />❑ <br />AND <br />❑ <br />— — <br />❑ ❑ <br />❑ ❑ <br />❑ <br />REPAIRS <br />CLEANED <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />REPAIRED ❑ <br />TEST AFTER <br />REPAIRS <br />LEAKED ❑ <br />LEAKED ❑ <br />OPENEDAT_PSID <br />AIR INLET PSID <br />PASSED ❑ <br />PSID <br />p,S/p <br />91 CHECK PSID <br />CHK VALI'E PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum air gap separation proridW Yes: ❑ No: ❑ Defector Aleter Reading: <br />REMARKS: IJQSS9t& Mecll`i!-al jSUjjdnj.5LINE PRESSURE: 55 PSI <br />Pt-cAj '(a ed -Fc ore FC e t 2 Z . CONFINED SPACE? _A <br />TESTERS SIGNATURE: _ c� i� c c CER— NO.: B4653 DATE: 1,2-16 — 05 <br />TESTERS NAME PRINTED: Brent AV. Cron TESTERS PHONE: (:_>) 879-1138 TESTERS EAIAIL: BC Back no%%s4z msfixom <br />REPAIRED BY: <br />FINAL TEST B <br />TE: <br />CERT. NO.: DATE: <br />CALIBRATIONDATE: 091:" 165 GAUGE: Mid \Vest Instruments MODEL: S30 SERVICE RESTORED? )'ES: _XNO: _ <br />I certlh• t ar this report is accurate, and r have used IC4C 1l6-190-I90 appm•ed lest meamds and rest equipment. <br />Back(Tow Pret entian Asserlrbl)r Test Report ittrtst be riled with focal Warer Disrricr br 0lrner of orentise. <br />