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Return reports to: <br /> BACKFLOW PREVENTION Backflow Prevention Program <br /> Everett,WA <br /> Allet"....1411 <br /> liii <br /> ASSEMBLY Public works <br /> TEST REPORT e1 <br /> E errettWA 98201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2000478 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 LBA REALTY LLC Phone: FAX: <br /> Equip Location FRONT OF BLDG IN IRRIGATION BOX-WEST SIDE. <br /> Downstrm Process IRRIGATION(LANDSCAPE) DCVA El RPBA ❑ PVBA [❑ AG ❑ Other DCVA <br /> New Install [ Existing ❑ Replacement ❑ Old SN# Proper Installation? ❑ Yes ❑ No <br /> Make of Assembly: WILKINS Model: 950XL Serial Number 3367252 Size: 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 [1Leaked U Leaked El #1 Check PSID Opened at PSID <br /> Failed U PSID PSID Air Gap Did not Open ❑ <br /> Clean Replace Part Clean Replace Part Clean Replace Part Check Valve <br /> New <br /> Parts ❑ ❑ 111 ❑ ❑ Held at PSID <br /> and ❑ ❑ ❑ ❑ ❑ ❑ Leaked ❑ <br /> Repairs ❑ El n E. - ❑ <br /> — Cleaned ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ Repaired ❑ <br /> Test After <br /> Repairs Leaked ❑ Leaked n <br /> Opened at PSID Air Inlet PSID <br /> Passed ❑ PSID PSID <br /> Failed [11 #1 Check PSID Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter: TT Separation: " Pass ❑ Fail H <br /> Remarks: (l 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: l <br /> l go <br /> Calibration Date: Make/Model Gauge# <br /> 1R - <br />