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Return reports to: <br /> BACKFLOW PREVENTION Backflow Prevention Program <br /> Everett,WA <br /> ASSEMBLY Public Works <br /> 3200 Cedar St. <br /> TESTm1/4401Wi <br /> `REPORT Everett WA 98201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2001411 Schedule Code 09-Sep Authorized Tester: <br /> Facility Name LBA REALTY LLC Commercial: ❑ Residential: 0 <br /> Mailing Address 600 UNIVERSITY ST#3025 Protection Type Premise <br /> Service Address 2600 W CASINO RD City: EVERETT Zip: 98204 <br /> Contact Name RAY ROBINSON Phone: FAX: <br /> Equip Location N OF 2600 BLDG PARKING LOT,BY FIRESERVICE RISERS <br /> Downstrm Process IRRIGATION(LANDSCAPE) DCVA 14 RPBA 0 PVBA ❑ AG ❑ Other DCVA <br /> New Install ❑ Existing ❑ Replacement ❑ Old SN# Proper Installation? [ Yes -I No <br /> Make of Assembly: FEBCO Model: 850 Serial Number 1143673 Size: 2" <br /> DCVA/RPBA DCVA/RPBA RPBA PVBAJSVBA <br /> CHECK VALVE#1 CHECK VALVE#2 <br /> Initial Test Opened at _ PSID Air Inlet <br /> Passed ❑ Leaked I I Leaked H #1 Check PSID Opened at PSID <br /> Failed ❑ PSID PSID Air Gap Did not Open <br /> Clean Replace Part Clean Replace Part Clean Replace Part Check Valve <br /> New <br /> Parts ❑ I ❑ ❑ ❑ ❑ Held at PSID <br /> and I ❑ [ ❑ ❑ ❑ Leaked ❑ <br /> Repairs ❑ ❑ ❑ I n n Cleaned ❑ <br /> C ❑ ❑ E ❑ ❑ Repaired ❑ <br /> Test After <br /> Repairs Leaked ❑ Leaked nAir Inlet PSID <br /> Opened at PSID <br /> Passed ❑ PSID _ PSID #1 Check PSID <br /> Failed I <br /> Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter: TT Separation: " Pass ❑ Fail <br /> Remarks: _ in USC 10th Edit. Line Pressure PSI - <br /> El Confinement <br /> Tester Signature: Cert.No.: Date: <br /> • <br /> Tester Name Printed: Testers Phone# ( <br /> Repaired By: Date: <br /> Final Test By: Cert.No.: Date: <br /> Calibration Date: Make/Model Gauge# ' K> vi.Q <br /> 1R <br />