HomeMy WebLinkAboutT_Backflow_180606.PDFReturn Reoort Information
By Mail: Mick Holte, Cross Connection Control Program
Utility Systems, 1055 South Grady Way, stn Floor
Renton, WA 98057
BV Fax: 425-430-724I
ByEmail: mholte@rentonwa.gov
Any questions, contact Mick at 425-430-7207 or by email
ACCOUNT #
Backflow Prevention Assembly Test Report
Publit \\lrrks
NAMEoFPREMISE Dylr^n ?lAl- commercial
sERVTcEADDRESs lQOct Jrnes Av" NE crrv ?r.'lr.'^ zrp
coNTACT PERSoN Ke^.-PHONE ( )
MODEL SERIAL NO
REMARKS:
IESTERS SIGNAT CERT. NO
tr Residential d-
cl?)o 5'l
FAX()
LocAIoNoFASSEMBLv )\{+tt Se.-pc Ur,, r tt.',t*' rn<ktr bcr
DoWNSTREAMPRoCESS I-{(\q.rtLb''\ System. oCvn f RPBAtr PVBAfI orHER
lrEw rlrsrnLrFExrsrNc E nrpucrvrrur E oro srn. *PRoPER TNSTALLATToN? ves El ruo E
MAKE oF A''EMBLY Fe Di I
'ilF,311ccn slzE l"
/',1(Yovn Wintt-bo-rrcvc TESTERSPHONE#(qLt)
DATE
CERT. NO.
B3t" 51r,3
FINAL TEST BY:DATE
CALIBRAToN DArE O \ t-lh- t tb GAUGE r OjOQ t Zro MoDEL-Ait)$!-Y!s -sERVtcE nrsronroz ves ff No E
INITIAL
TEST
PAssED (
FAITED E]
DCVA / RPBA
CHECK VALVE NO.1
lenreo E
'z q PsrD
DCVA / RPBA
CHECK VALVE NO.2
lrnxro fl
Z.L PsrD
RPBA
oPENEDAT_PStD
#1 CHECK _PStD
AIR GAP OK? -
PVBA/SVBA
AIR INLET
oPEN ED AT _PStD
DrD Nor oPEN tr
NEW
PARTS
AND
REPAIRS
CLEAN REPNCE
trtr
trtr
trtr
trtr
CTEAN REPLACT PART
trtr
trtrtrtrtrtr
CLEAN REPLACT PART
trtr
trtr
trtrtrtr
CHECK VALVE
HELD AT _PS|D
LEAKED tr
CLEANED tr
REPAIRED tr
TEST AFTER
REPAIRS
PASSED E]
FAILED tr
LEAKED tr
PSID
LEAKED tr
PSID
OPENED AT -PSID
#1 CHECK PSID
AIR INLET - PSID
CHK VALVE PSID
AIR GAP INSPECTIoN: Required minimum air gap separation provided? Yes E No D Detector Meter Reading b 3 Zi'f f Otf
LtNE PRESSURE _PSl
CoNFTNED spncn 'flO
DArE 3f bf brq'
TESTERS NAME PRI
REPAIRED BY:
Cte r; n
I certify thot this report is accurote, ond I hove used WAC 246-290-490 opproved test methods ond test equipment.