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CZT.)2-- <br /> f 'L <br /> MacDonald-Miller 1 S-672 ^ �° <br /> FACILITY SOLUTIONS <br /> Backflow Prevention Assembly Test Report <br /> ASSEMBLY ID: <br /> NAME OF PREMISE t/�Cove 6 Gji I, were 4 COMMERCIAL &RESIDENTIAL O <br /> SERVICE ADDRESS D--413 O ��k 5 A- CITY i'� ZIP <br /> CONTACT PERSON ear C� '� <br /> C Phone ( ) Fax ( ) <br /> LOCATION OF ASSEMBLY La „ _ - CI , to /r. 12-,y \ Y <br /> DOWNSTREAM PROCESS v - DCVA 0 RPBA tit PVBA 0 OTHER: <br /> NEW INSTALL, EXISTING 0 REPLACEMENT ❑ OLD SER. # PROPER INSTALLATION? YESPNO 0 <br /> MAKE OF ASSEMBLY\V. Sc�c- MODELL pC..7q co--- SERIAL NO. 7Z GO ) SIZE q /Z <br /> INITIAL DCVA/RPBA CHECK DCVA/RPBA CHECK RPBA PVBA SVBA <br /> TEST VALVE NO. 1 VALVE NO. 2 OPENED AT 3• PSID AIR INLE <br /> LEAKED 0 LEAKED ❑ #1 CHECK ti. 0 PSID OPENED AT, <br /> T Z PSID <br /> PASS 9kO r.1 PSID PSID AIR GAP OK? DID NOT OPEN 0 <br /> FAIL 0 <br /> NEW CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br /> PARTS AND o o ^ O 0 O O HELD AT SID <br /> REPAIRS ❑ o i ❑ ❑ ❑ 0 LEAKED O , <br /> O ❑/ O O O O <br /> ❑ ❑ o O CLEAN 5V O <br /> REPAIRED 0 <br /> TEST <br /> AFTER LEAKED o LEAKED O OPENED AT P D AIR INLET ID <br /> REPAIRS <br /> PASS OD / PSID PSID #1 CHECK .7- PSID CHK VAL PSID <br /> IIR GAP INSPECTION:Required minimum air gap separation provided? Yes 0 No 0 Detector Meter Reading <br /> tEMARKS: LINE PRESSURE 5-2- <br /> I <br /> CONFINED SPACE? }/u[� <br /> RS <br /> _ESTESIGNATURE: - . 11.'..--;;;---- - _ _..-.....-`------- - — C----- BERT. NO.65---r,- `2 DATE -8 i/di /C <br /> "ESTERS NAME (PRINT): op i / I-6:\'‘ Phone at) a le - q 6� <br /> tEPAIRED BY: DATE <br /> rINAL TEST BY: CERT. NO. DATE <br /> :ALIBRATION DATE 2/5/1 ¶ GAUGE # C7� �> 0 MODEL /n0vre c-t Y <br /> certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. <br /> • <br /> 0..1i <br />