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• <br /> BACKFLOW PREVENTION Return reports to:BacicflowPreventionProgram <br /> Everett,WA <br /> /41140, ASSEMBLY Public works <br /> oisvenimili <br /> TEST REPORT Everett tteWA t98201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 31688 Schedule Code NEVER Authorized Tester: <br /> Facility Name LBA REALTY LLC Commercial: [] Residential: ❑ <br /> Mailing Address 600 UNIVERSITY ST#3025 Protection Type PREMISE <br /> Service Address 2610 W CASINO RD City: Zip: <br /> Contact Name ROB DUTCHER Phone: FAX: <br /> Equip Location COMPRESSOR ROOM OF MAINTENANCE GARAGE. <br /> Downstrm Process CHILLER DCVA 0 RPBA El PVBA 0 AG ❑ Other RPBA <br /> New Install _ Existing n Replacement H Old SN# Proper Installation? Yes n No <br /> Make of Assembly: WATTS Model: 909QT Serial Number 636086 Size: 3/4" <br /> DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA <br /> CHECK VALVE#1 CHECK VALVE#2 <br /> Initial Test Opened at PSID Air Inlet <br /> Passed LILeaked Li Leaked El #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 C ❑ ❑ n ❑ Held at PSID and n n E. •__ ❑ _ Leaked n <br /> Repairs ❑ _ ❑ ❑ ❑ ❑ Cleaned n <br /> n n ❑ [ ❑ ❑ Repaired [ <br /> Test After <br /> Repairs Leaked [] Leaked <br /> Opened at PSID Air Inlet PSID <br /> Passed ❑ PSID PSID <br /> Failed El Check PSID Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter: If Separation: " Pass -1 Fail n <br /> Remarks: USC 10th Edit. Line Pressure PSI <br /> Confinement <br /> Tester Signature: Cert.No.: Date: <br /> Tester Name Printed: Testers Phone# ( ) , <br /> Repaired By: Date: <br /> Final Test By: Cert.No.: Date: <br /> (i <br /> r / <br /> Calibration Date: _ Make/Model Gauge# li ''ll)' <br /> 1R <br />