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GC;IG-CIC.� <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />NAI%IF.OFPRFNUSF. SING11 asamy RESIDENCE <br />❑ ResidenllalA <br />SERVICE ADDRESS IQ416 HOSE OO AVE(LOT 41 CITY EYYJMTT ZIP _. <br />CONTACT PERSON MIKE nmATA 1'IIONE (206) 819-7413 FA.0 ._ <br />LOCATION OF ASSEMBLY GARAGEIYALL <br />DOWNSTREAM PROCESS FIRF SPRINKr cue DCVA )( RPIIA ❑ 1'VI1A ❑ OTHER <br />NEW INSTALI.X EXISTING ❑ REPLACEMENT ❑ OLD SER. N PROPER INSTALLATION? YES)i(NO ❑ <br />MAKE OF ASSEMBLY S 11IODEI. ��SF-RIAL NO. SIZE IA Y <br />INITIAL, <br />n('VA/Rt'IIA CHECK <br />MA I EPA CHECK <br />VALVE NO.2 <br />RIBA <br />OPENED AT PSID <br />I'VIlASVIIA <br />AIR INLET OPENED <br />TEST <br />PASSE I)� <br />VALVF.NO.1 <br />LEAKED ❑ <br />LEAKED ❑ <br />AIR GAP OK? <br />AT PSID <br />FAILF)❑ <br />CLOSEDTIGHTA <br />CLOSEDTIGIIT)< <br />F2 PSID <br />_, � —PSID <br />DID NOT OPEN ❑ <br />TEST AFTER <br />LEAKED ❑ CLOSED <br />LEAKED ❑ CLOSED <br />OPENED AT_PSID 41 <br />AIR INLLT PSID <br />RIA'AIRS <br />TIGHT <br />TIGI IT❑ <br />CIIECK PSIn <br />CHK VALVE PSID <br />PASSED❑ <br />FAILED ❑ <br />PSID <br />PSID <br />AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Reading <br />WA STATE APPROVED ASSEIIIBLV? YcsX No ❑ <br />REMARKS: <br />LINE PRESSURE—L! -7 PSI 11 <br />TESTERS SIGNATURE: IA � L� CERT. NO. RJ848 DATE <br />TESTERS NAME PRINTED: Kennelh it. Robinson-Elmslic TESTERS PHONE N (360) 403-7462 <br />REPAIRED BY: <br />FINAL TEST SY: CERT. NO. DATE _ <br />CALIBRATION DATE: 10/3/2011 GAUGE N 372448 MODEL: Conbroco 40-200-Tk5 TYPE: 5 Valve <br />SERVICE RESTORED? YESIX NO ❑ <br />1 certify that this report is accurnte, anrt I hoe used IVAC 246-290490 approved fast methods and rest equipment. <br />