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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />AACRA Backflow Assen;Wy Testing B Service <br />PNIB A-11, 621 S.R. 9 N.E., Lake Stevens, WA 98258 <br />Phone:475-334-4507 Pager:425438-5316 Fax:425-334-6526 X� G <br />AACRABA990DM PL30YOUNGLAV983PT <br />ACCOUNT# <br />NAME OF PREMISE 3F V r �� �� k,r� �t ,ti V\� +, r Commercial Residential ❑ <br />SERVICE ADDRESS + `r am 7 R �\ c yr CITY ZIP 1,4. V J <br />CONTACT PERSON rV CPHONE (V'1;) _*- `a'l - ti �0 FAX( ) <br />LOCATION OF ASSEMBLY � ,_ v 1 0 F, \ C 'C -A r G 1h1 <br />DOWNSTREAM PROCESS V wc,'A\V� (».'ant? DCVA ❑ RPBA� PVBA ❑ OTHER <br />NEW INSTALL EXISTING ❑ REPLACEMENT ❑ OLD SER. # _ PROPER INSTALLATION? YES kNO ❑ <br />MAKE OF ASSEMBLY ' ti S MODEL !) `J X, k SERIAL NO. °,O (e Q , SIZE r S <br />DCVA/RPBA <br />D VA/RPBA <br />RPBA <br />PVBA/SVBA <br />INITIAL <br />CHECK VALVE NOA <br />CHECK VALVE N0.2 <br />AIR INLET <br />TEST <br />OPENED AT_ PSID <br />CLOSED TIGHT ❑ <br />CLOSEDT'I(�II'1' ❑ <br />OPENED AT PSID <br />LEAKED IA <br />LEAKED ❑ <br />#1 CHECK PSID <br />PASSED ❑ <br />PSID <br />AIR GAP OK? J. 5 <br />DID NOT OPEN ❑ <br />FAILED <br />_ PSID <br />CLEAN REPLACE PART — <br />CLEAN REPLACE PART <br />CLEAN REPLACE PART <br />CHECK VALVE <br />NEW <br />aj ❑ <br />❑ ❑ <br />❑ I$ 0.a hE, <br />HELD AT PSID <br />PARTS <br />l <br />❑ ❑ <br />❑ ❑ <br />❑ � n,s� <br />LEAKED ❑ <br />AND <br />REPAIRS <br />❑ ❑ <br />❑ ❑ <br />❑ ®—' <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />CLEANED <br />- - -_-- --- <br />REPAIRED ❑ <br />TEST AFTER <br />-- _--- <br />—--- —- <br />— -------- <br />REPAIRS <br />LEAKED ❑ <br />LEAKED ❑ <br />OPENED AT PSID <br />AIR INLET PSID <br />PASSED �K <br />-1 , 9� PSID <br />r C\ �s� PSID <br />#1 CHF,CK�j tPSID <br />CHK VALVE _PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum air gap separation provided? Yes D No ❑ Detector Meter Reading <br />REMARKS: <br />TESTERS SIGNATURE: <br />LINE PRES.';URF PSI <br />CONFINED:IPA.CF? NO <br />CcRT. NO. B-3497 DATE � I` I1�- I d <br />I STERS NAME PRINTED: _Lewis W. Young__ TESTERS PHONE # ( 425 ) 334-4507_ <br />CAL. DATE I _ / /�L GAUGE # ❑ 03050953 bk12050050 MAKE_ Midwest MODEL 945_ <br />REPORT TO y G �, — SERVICE RESTORED? YES NO ❑ <br />I certify shot this report it accwalt, and / have used a'AC 146-190-490 approved test methods and test equoment. <br />