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I <br /> QBTS' BACKFLOW TESTING <br /> & SERVICE, INC <br /> 425-334-3350 <br /> BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br /> ACCOUNT# -�-+ <br /> NAME OF PREMISE ( t�'�3&AkJ AA-A - Commercial X Residential❑ <br /> SERVICE ADDRESS Z7-3'0MAAi&Ad 111 g14 2 T CITYl✓�'r�1a ZIP <br /> CONTACT PERSON PHONE( ) FAX( ) <br /> LOCATION OF ASSEMBLY AWn)Cn Ea. 1AI� �7 j ( % i + �lnl7l Sihlk,��c�/ffJG1. <br /> DOWNSTREAM PROCESS Ai 4i GAJ l�i�'� DCVA ❑ RPBAfii PVBA ❑ OTHER <br /> NEW INSTALLfi4-EXISTING ❑ REPLACEMENT ❑ OLD SER# PROPER INSTALLATION?YES JrNO❑ <br /> MAKE OF ASSEMBLY_tAM — MODEL 4 F('`)C')`�Vn,3C�EIII AL NO. -I 3 qI g SIZE <br /> DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA <br /> INITIAL CHECK VALVE NO.1 CHECK VALVE NO.2 AIR INLET <br /> TEST OPENED AT3,16-1 PSID <br /> OPENED AT PSID <br /> + LEAKED ❑ LEAKED ❑ #1 CHECK 1?,8 PSID <br /> PASSED R V DID NOT OPEN ❑ <br /> FAILED ❑ PSID PSID AIR GAP OK? =— <br /> CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br /> NEW ❑ ❑ ❑ ❑ ❑ ❑ HELD AT PSID <br /> PARTS ❑ ❑ ❑ ❑ - ❑ ❑ LEAKED ❑ <br /> AND El EJ ---- 1:1 1:1 El El --- <br /> REPAIRS - CLEANED ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ REPAIRED ❑ <br /> TEST AFTER <br /> REPAIRS LEAKED ❑ LEAKED ❑ OPENED AT PSID AIR INLET PSID <br /> PASSED ❑ PSID PSID M CHECK PSID CHK VALVE PSID <br /> FAILED ❑ <br /> AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No❑ Detector Meter Reading <br /> REMARKS: LINE PRESSURE/1'-0 PSI <br /> WSDOH PROVED DEVICE? YES 12rNO❑ CONFINED SPACE? <br /> TESTERS SIGNATURE: '`''''v CERT.NO. B0461 DATE <br /> TESTERS NAME PRIN D: Thomas Wahlman TESTERS PHONE# (206) 255-9646 <br /> REPAIRED BY: DATE <br /> FINAL TEST BY: CERT. NO. DATE <br /> CALIBRATION DATE 02/17/1k GAUGE#06132911 MODEL Midwest 830 SERVICE RESTORED? YES&' NO❑ <br /> I certify that this report is accurate,and I have used WAC 246-290-490 approved test methods and test equipment J�) <br />