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Return reports to: <br /> • • BACKFLOW PREVENTION Backflow Prevention Program <br /> � � Everett,WA <br /> ASSEMBLY Public works <br /> TEST REPORT WA <br /> Everett t98201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2000601 Schedule Code 09-Sep Authorized Tester: <br /> Facility Name LBA REALTY LLC Commercial: ❑ Residential: 0 <br /> Mailing Address 600 UNIVERSITY ST#3025 Protection Type Bypass <br /> Service Address 2600 W CASINO RD City: EVERETT Zip: 98204 <br /> Contact Name LBA REALTY LLC Phone: FAX: <br /> Equip Location NORTH SIDE OF PROPERTY-EAST VAULT <br /> Downstrm Process FIRESERVICE BYPASS DCVA e RPBA ❑ PVBA ❑ AG ❑ Other DCVA <br /> New Install ❑ Existing = Replacement ❑ Old SN# Proper Installation? ❑ Yes ❑ No <br /> Make of Assembly: AMES Model: Serial Number 23480 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 0Leaked ElLeaked ❑ #1 Check PSID Opened at PSID <br /> Failed ❑ PSID PSID Air Gap Did not Open H <br /> Clean Replace Part Clean Replace Part Clean Replace Part Check Valve <br /> New <br /> Parts I I ❑ iii] ❑ CI EllHeld at PSID <br /> and ❑ H ❑ [ ❑ Leaked ❑ <br /> Repairs ❑ ❑ ❑ ❑ ❑ ❑ Cleaned ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ Repaired LJ <br /> Test After <br /> Repairs Leaked ❑ Leaked Air Inlet PSID <br /> Opened at PSID <br /> Passed ❑ PSID PSID #1 Check PSID <br /> Failed ❑ Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter: ft Separation: " Pass ❑ Fail H <br /> Remarks: I I USC 10th Edit. Line Pressure PSI <br /> lin 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 /> (;71 <br /> l <br /> Calibration Date: Make/Model Gauge# ! <br /> 1R <br />