Laserfiche WebLink
Return reports to: <br /> BACKFLOW PREVENTION Backflow Prevention Program <br /> ASSEMBLY <br /> Public Works <br /> 41116Villimia <br /> ,441.4.-14 <br /> TEST REPORT Everett WA Cedar 198201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2000600 Schedule Code 09-Sep Authorized Tester: <br /> Facility Name LBA REALTY LLC Commercial: ❑ Residential: ❑ <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 N SIDE OF PROPERTY IN GRASS-EAST VAULT <br /> Downstrm Process FIRESERVICE DCVA f RPBA ❑ PVBA ❑ AG ❑ Other DCDA • <br /> New Install ❑ Existing ] Replacement ❑ Old SN# Proper Installation? [ Yes ❑ No <br /> Make of Assembly: AMES Model: Serial Number LN0334 Size: 8" <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 U Leaked Leaked ❑ #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 ❑ 117 El CI 111 El Held at PSID <br /> Parts <br /> and ❑ ❑ ❑ H [ ❑ " Leaked ❑ <br /> Repairs ] ❑ ❑ I I ❑ ❑ Cleaned ❑ <br /> ❑ ❑ ❑ ❑ ❑ L Repaired ❑ <br /> Test After <br /> Repairs Leaked Li Leaked ❑ AiPSID <br /> Opened at PSID Air <br /> Passed ❑ _PSID PSID #1 Check PSID <br /> Failed IDCheck PSID <br /> Air Gap Inspection: Supply Pipe Diameter: ti Separation: " Pass Li Fail ❑ <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 /> /7 4 b <br /> Calibration Date: <br /> _ Make/Model Gauge# <br /> 1R <br />