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( Terrir, <br /> Return reports to: <br /> BA KFLOW PREVENTION Backflow Prevention Program <br /> ASSEMBLY <br /> Ever <br /> WA <br /> 3200 Cedar St. <br /> TEST REPORT Everett WA 98201 <br /> FAX: (425)257-8882 <br /> XC2 Assembly 30398 Schedule Code 09-Sep Authorized Tester: <br /> Facility Name EVERETT COMMUNITY COLLEGE Commercial: ❑ Residential: 0 <br /> Mailing Address 2000 TOWER ST Protection Type IN-PREMISE <br /> Service Address 2333 SEAWAY BLVD City: Zip: <br /> Contact Name PAT SNOWDEN Phone: FAX: <br /> Equip Location NE OF DOMESTIC METER 7' <br /> Downstrm Process IRRIGATION(LANDSCAPE) DCVA E RPBA -;.❑ ..PVBA .,❑ AG ❑ Other DCVA <br /> New Install ; I Existing Replacement Old SN# Proper Installation? I I Yes 1 I No <br /> Make of Assembly: RAIN BIRD Model: 150R Serial Number 09.6X4 Size: 1 1/2" <br /> DCVA/RPBA DCVA/RPBA RPBA PVBA/SVBA <br /> CHECK VALVE#1 CHECK VALVE#2 Opened at PSID Air Inlet <br /> Initial Test <br /> Leaked j ) Leaked <br /> Passed 1 <br /> #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 /> I I 1 I I 1 I Held at PSID <br /> Parts <br /> and I I I I _ Leaked <br /> Repairs Fl <br /> — — _ Cleaned <br /> LI - Repaired <br /> Test After <br /> Repairs Leaked I I LeakedAir Inlet PSID <br /> Opened at PSID <br /> Passed PSID PSID <br /> Failed #1 Check PSID Check PSID <br /> Air Gap Inspection: Supply Pipe Diameter:, ; T, " Separation: " Pass Fail <br /> SRemarks: vi2, \---" ` "" USC 10th Edi . Line Pressure PSI <br /> Nn ) . 4._ It . . .# ; CIO AS --A LL [7 Confinement <br /> Tester Signature:lr 4t `` J " Cert. No.: Date: <br /> Tester Name Printed: Testers Phone# ( ) <br /> Repaired By: Date: <br /> Final Test By: Cert. No.: Date:\ <br /> Calibration Date: Make/Model Gauge# <br /> 1R <br />