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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />(;NAMEOFI'REnIISE SINGLE EAMILYHESIDENCE <br />❑ Residentlall9 <br />SERVICEADDRFSS 10420 ROSFIVOOD ANT(IOT51 CITY FVFRFTI' ZIP <br />CONTACT'PERSON MIKEIIIRATA PHONE.. (206)819-7413 FAX <br />LOCATION OF ASSEMBLY <br />DOWNSTREAM PROCESS FIRE SPRINKI FRS DC\'A )� RPRA ❑ ITBA ❑ OTl1ER <br />NE1V INSTALLKEXISTING n❑ lit P ACEMEnT ❑ OLD SER. H PROPER INSTALLATION? YES)NO ❑ <br />HAKE OF ASSITIDLI' 4-,en, 5 MooEi, w00.6 SERIALNO. O/1370 SIZE <br />INITIAL <br />TEST <br />IS\SSIiD 9i <br />F.\TEFL(❑' <br />DCVA/ RPRA CIIISCK <br />VALVENO,I <br />LEAKED ❑ <br />CLOSED TIGRT� <br />DCVA/RPRA CDECK <br />VALVE NO.2 <br />LEAKED ❑ ,.,r <br />CLOSEDTIGHTji <br />RPRA <br />OPENED AT PSID <br />AIR GAP OK? <br />PViIA/SVIIA <br />AIR INLET OPENED <br />AT_PSID <br />2 .t% PSID <br />I•7 PSID <br />DID NOT OPEN ❑ <br />TEST Ah1'F.R <br />LEAKED ❑ CLOSED <br />LEAKED ❑ CLOSED <br />OPENED AT_PSID 01 <br />AIR INLET PSID <br />RETAIRS <br />PASSED❑ <br />TIGHT <br />TIGHT <br />Cl IECK PSID <br />CIIKVALVE _PSID <br />FAILED ❑ <br />PSID <br />PSID <br />AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Rending <br />W'A S7'A'1'E API'ROVED ASSEMBLY? YesX No ❑ <br />REMARKS: <br />LINE PRESSURE 67 Psi TESTERS SIGNATURE: J/I�t CERT. NO. B-3848 DATE 'y/ <br />TESTERS NAME PRINTED: Kenneth 11, Robinson-Elmslie TESTERS PHONE It (3601403-7462 <br />REPAIRED BY: <br />FINAL TESTBV: CERT. NO. DATE _ <br />CALIBRATION DATE: 10/3/2011 GAUGE 0 372448 MODEL: Conbrnco 40-200-Tk5 TYPE: 5 Vnlve <br />SERVICE RESTORED? VESX NO 0 <br />I certify that this re port is arenrate, laid I have used II61C246-290490 approved test methods and rest equipment. <br />