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i <br /> CZ) 15d -I Z7-- V <br /> MacDonald-Miller <br /> FACILITY SOLUTIONS <br /> Backflow Prevention Assembly Test Report <br /> ASSEMBLY ID:,;, <br /> NAME OF PREMISE C)rc.)..),� ll k�� �4- COMMEERCIAL 7 RESIDENTIAL ❑ <br /> SERVICE ADDRESS a� ' V --/L > CITY E '1- ZIP <br /> DONTACT PERSON 0 U� Phone ( ) Fax ( ) <br /> _OCATION OF ASSEMBLY A _ 1 oq / S,,,,re Q(,/'5 ry,ts rUUi"' <br /> !' "� <br /> DOWNSTREAM PROCESS A , jc,�(Af' DCVA 0 RPBA,r PVBA 0 OTHER: <br /> '4EW INSTALLAEXISTING op REPLACEMENT o OLD SER.# PROPER INSTALLATION? YESyq NO o <br /> HAKE OF ASSEMBLY WL1-*S.- MODEL(- C)011 CO---- SERIAL NO. SIZE I j 2 <br /> INITIAL DCVNRPBA CHECK DCVA/RPBA CHECK RPBA PVBA SVBA <br /> TEST VALVE NO. 1 VALVE NO. 2 OPENED A1-71.11 PSID AIR INLET <br /> LEA ED❑ LEAKED o #1 CHECK G�', (1 PSID OPENED AT PSID <br /> Pts _ O PSID PSID AIR GAP OK? \/ DID NOT OP ❑ <br /> FAIL 0 <br /> NEW CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE <br /> PARTS AND ❑ ❑ oO ❑ 0 HELD AT PSID <br /> REPAIRS O ❑ ❑ O E <br /> ❑❑O CLEAN ❑ <br /> REPAIRED O <br /> a <br /> TEST <br /> AFTER LEAKED LEAKED 0 OPENED AT PSID AIR INLET P D <br /> REPAIRS <br /> PASS O PSID PSID #1 CHECK PSID CHK VALVE. PSID <br /> FAIL 0 <br /> 1111 GAP INSPECTION:Required minimum air gap separation provided? Yes 0 No 0 Detector Meter Reading <br /> tEMARKS: LINE PRESSURE 1 <br /> ' - CONFINED SPACE? r\.e} <br /> 'ESTERS SIGNATURE: — --/ -- - - --- —-----— ---C—E----R-T. NO.NO---.13M. <br /> r7�g/(I <br /> dt 'r- <br /> 'ESTERS NAME (PRINT): , . Z. ' G,'� Phone ) .NbSq 6 <br /> tEPAIRED BY: DATE <br /> 'INAL TEST BY: �r,,� CERT. 0.� �� DATE <br /> :ALIBRATION DATE 2�3 /1 GAUGE #CC4070S(4 Li MODEL ��c2 4) �L( <br /> certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. <br />