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Return reports to: <br /> #00111P <br /> BACKFLOW PREVENTION <br /> .ASSEMBLYBackflow Prevention Program <br /> Everett,WA <br /> e"Abz--- <br /> Public Works <br /> TEST REPORT EverrOetteWA 9820 <br /> 1 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2000614 Schedule Code 09-Sep Authorized Tester: <br /> Facility Name LBA REALTY LLC Commercial: ❑ Residential: 0 <br /> Mailing Address 600 UNIVERSITY ST#3025 Protection Type In-Premise <br /> Service Address 2600 W CASINO RD City: EVERETT Zip: 98204 <br /> , Contact Name LBA REALTY LLC Phone:• FAX: <br /> Equip Location IN RESTROOM <br /> Downstrm Process NON-POTABLE WATER FOR DCVA ❑ RPBA El PVBA ❑ AG ❑ Other RPBA <br /> New Install ❑ Existing ❑ Replacement [] Old SN# Proper Installation? ❑ Yes ❑ No <br /> Make of Assembly: WATTS Model: 009M2QT Serial Number 148812 Size: 1 1/2" <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 ❑ Leaked ❑ Leaked ❑ #1 Check PSID Opened at PSID <br /> Failed ❑ PSID PSID Air Gap Did not Open n <br /> Clean Replace Part Clean Replace Part Clean Replace Part Check Valve <br /> New <br /> Parts Li ❑ El El ❑ Held at PSID <br /> and ❑ ❑ ❑ E. ❑ ❑ Leaked U <br /> Repairs ❑ ❑ Cl ❑ ❑ E <br /> Cleaned ❑ <br /> ❑ ❑ n• ❑ ❑ U Repaired ❑ <br /> Test After <br /> Repairs Leaked ❑ Leaked EIAir Inlet PSID <br /> Opened at PSID <br /> Passed ❑ PSID PSID #1 Check PSID <br /> Failed n Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter: ti Separation:• " Pass ❑ Fail Li <br /> Remarks: 1 1 USC 10th Edit. Line Pressure PSI <br /> gi Confinement <br /> Tester Signature: Cert.No.: Date: <br /> Tester Name Printed: Testers Phone# ( ) <br /> Repaired By: Date: <br /> Final Test By: Cert.No.: Date: (/`i <br /> Calibration Date: Make/Model Gauge# l V <br /> 1R <br />