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.. . � , . • . . . .. . . .. .... .. .., . . _.., . . . . . . .. t. <br /> , P� �� -°� <br /> � BACKFLOW PREV�NTION ASSEMBLY TEST REPORT <br /> DFNNIS P M�LAUGHLIN ' ���}' GREATER SEA7T�E AREA <br /> STATE CERTIFIED ' T�'-' � '> `=``�-,�!`'� PHONE dc FAX:(206}761-95J1 <br /> ._.. . • <br /> INDF.PENDENTOPERATOR �- �" "!\ ^• '�--- -' -i--' H CELLPHONE:(206�l19-0774 <br /> t-1�i r�t�, r: I <br /> `_��l J �'� .?/ l:,"/ �� �.:_�A-�i <br /> ACCOUNT N ` _—... \ ,� • <br /> �1 i— >i � . <br /> NAME OP PREMISE �I !J�/^ G f� // T�- � �'� 1� _Canmerciat❑ Rnfde�tid� <br /> SERVICE ADDRFSS C' ��f I r-1 1�J���%ri r L CITY l'� ��`�� T Zt� ������ <br /> CONfACT PERSON ��=�� ��� ; ��/ F�N HONE( ) FAX( ) <br /> LOCATIONOFASSf.MBLYIi:. �%`;y Errr Ty ?i� //--[.lr <br /> DOWNSTREAM PROCESS ��S, � ��Z� DCVA ❑ RPBA� PVBA ❑ OTHER <br /> NEW INSfALL�EXISI7NG 0 REPWCEMENT❑ OID SER.M PROPER IN5fALL►TION!YFS�SNO O <br /> ��-�-- - i �, 1 -� <br /> MAKEOFASSEMBLY �' - %�'Ti �' MODEL !�C'�!SERIALNO� �' �' / � SIZE /' <br /> DCVA/RPBA DCVA/RPBA $P@e ��BA <br /> INITIAL CHECK VALVE NO.1 CHECK VALVF.N0.2 . � NR 1NLHT <br /> TEST OPGNEDATL�PSID <br /> CI.OSf?Dl1GHT'� CI.OSGD'IlGll'I'� OPENEDAT PSID <br /> LEAKED C1 � LGAKED 0 � b� CHECK %� � PS[D <br /> PASSED� DID NOT OPEN O <br /> FA�.,ED T]'� PSID _PSID A1R GAP OK?� <br /> i <br /> CLEa\ QP.PI.ACF. P.VfT CLP.�N 81[PI.ACF. PART f1.L,6C Yf.PIM'L PART CHECK VALVE <br /> NEW � � � � � � HELD AT PSID <br /> PARTS ❑ ❑ ❑ O ❑ O LEAKED O <br /> AND <br /> REPAIRS � � � � � � -- CLEANED ❑ <br /> ❑ ❑ - ❑ ❑ � ❑ REPAIRED ❑ <br /> TFST AFTER <br /> REPAIRS �,EAK[D 0 LEAKEU ❑ OPENEU AT�PSI'd AIR IAILET PSID <br /> PASSED ❑ PSID PSID �� CIiECK__PSID CHK VALVE__PSID <br /> FAILED ❑ <br /> AIR GAP INSPECTION N�ha�mim�����tr gep.qemi��Moa,fal• Ye.s❑ Ao❑ Detector Dfe�a Radi�� <br /> REMARKS: __ _ ________ _.________ LINEPRESSURL ,PSI <br /> . / CONFINED SPACE? h� <br /> " -- __ ,, . ----- -- i, % -. <br /> . : ' NAT 0205 DATE ,!%��•;..� ,�. �, <br /> TESTERS SICNATUREc� /i - ,. CERT. NO. _ <br /> TESTERS NAME PFtINTED: nF.NNIS P. MCLAUCHI.IN 7'ESTERS PHONE N( 2116 ) 36�-9531 <br /> RtiPA1RED Bl': DATE <br /> FINAL"PES7'l3Y: ----- --- ------ CERT.NO._ _`DATE --- <br /> ; � MIUN'EtiT <br /> CALIBRATION DATE �� /'�J��GAUGE M 35�3zz MOUEL 5311 SERVICE RESTORED? YES� NO❑ <br /> — � � <br /> !cerriJ,p rAa Ai�.rpon i�acrurar.��d 1lu�+r r.A NAC SIM1240.IM app.oird u<r metAoh��teu qriprwnr. <br /> Ni.1111.�6TU�'.��IT!R!f iNrNlO�REIY�RifU11l <br />