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Return reports to: <br /> "11"*'10040„44, 0,0 op/07-411 BACKFLOW PREVENTION Backilow Prevention Program <br /> ASSEMBLY Pub wa ks <br /> TEST REPORT Everett tteWA 198201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 2001236 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. RAY ROBINSON Phone: FAX: <br /> Equip Location STEAM CLEANER-BEHIND STEAM CLEANING STATION <br /> Downstrm Process DCVA E] RPBA EE PVBA ❑ AG D Other RPBA <br /> New Install ❑ Existing n Replacement ❑ Old SN# Proper Installation? n Yes ❑ No <br /> Make of Assembly: WATTS Model: 009M3QT Serial Number 290561 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 ElLeaked ElLeaked ❑ #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 111H El ❑ ❑ LiHeld at PSID <br /> and ❑ ❑ ❑ ❑ ❑ ❑ Leaked ❑ <br /> Repairs ❑ ❑ ❑ ❑ ❑ ❑ Cleaned ❑ <br /> ❑ ❑ ❑ ❑ ❑ E Repaired ❑ <br /> Test After <br /> Repairs Leaked n Leaked ❑ Air 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: tt Separation: " Pass ❑ Fail ❑ <br /> Remarks: USC 10th Edit. Line Pressure PSI <br /> x Confinement <br /> Tester Signature: Cert.No.: Date: <br /> Tester Name Printed: Testers Phone# ( ) <br /> Repaired By: Date: <br /> "P <br /> Final Test By: Cert.No.: Date: il , <br /> Calibration Date: Make/Model • Gauge# <br /> IR <br />