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Home My WebLink AboutFire Main - Fire Bypass Backflow Cert.pdfReturn Report lnformation By Mail: Mick Holte, Cross Connection Control Program Utility Systems, 1055 South Grady Wa¡ 5th Floor Renton, WA 98057 , ByFax 425-430-724L By Email: mholte@rentonwa.sov Any questions, contact Mick at 425-430-7207 or by email ent öäe Public \.Volks ACCOUNT It Backflow Prevention Assembly Test Report P,srnax¡ NAME OF PREMISE SERVICE ADDRESS CONTACT PERSON LOCATION OF ASSEMELY DOWNSTREAM PROCESS CITY alD /Residentialtr%s( FAX( ) {*r"on PVBA fl orHER-DCVA./ NEW rNsrALL Mexrsrrrue E ncpncEnnENï E oLD sER. s PROPER INSTALLATION? YES M/NO-tr MAKE OF ASSEMBLY DEL NO. INIT]AL TEST PASSED y' FAILED T] AIR GAP INSPECIIONT Required minimum air gap separation provided? Yes E No tr Detector Meter Reading oM),4 REMARKS:9ry36þ t{ffi-d æfr4 I n*l NE PRESSURE bS '', SPACE? \IO DCVA / RPBA CHECK VALVE NO.l lrnrro EI D pcvA / RPBA CHECK VATVE NO.2 ucer¡o fl L RPBA OPENED AT- PSID #l CHECK_PSID AIR GAP OK? - PVBA/SVBA AIR INLFT 0PENED AT_PSrD DID NOT OPEN tr NËW PARTS AND REPAIRS CI,EAN REPI.ACÉ PART tr E tr E] tr n tr E CTEAN REPI.ACE PAßT n EI EI tr trtr tr tr CLEAN RÊPLACÊ PARI tr trn E u E] Eu CHECK VALVE HELD AT -PSID LEAKED EI CLEANED REPAIRED TEST AFTER REPAIRS PASSED tr FAILED tr LEAKED tr -.-P5ID LEAKED tr PSID OPENED AT-PSID fll CHECK _PSID AIR INLET- PSID CHK VALVE . PSID TESTERS SIGNATU TESTERS NAME PRINTED: REPAIRED BY: CERT. NO. TESTERS PHONE # (4â ZSvSh r+ t /rNAL TEST CERÏ. NO. cALTBRAToN oarc 02 I&-.:ß-GAUGE * l7¡u435 vioo SERVICE RESTORED? "' y'*O N I cenify that this report is accurate, ond t have used WAC 246-290-490 opproved test methods and test equipment. Return Report lnformation By Mail: Mick Holte, Cross Connection Control Program Utility Systems, 1055 South Grady Way, 5'h Floor Renton, WA 98057 ByFax 425430-7?41 By Email: mholte@rentonwa.sov Any questions, contact Mick at 425-430-7207 or by email ent öäÐ Public \\¡olks Backflow Prevention Assembly Test Report ACCOUNT it NAME OF PREMISE fblR/esidential trmslo4 E E-lf 'Pçø€Pg-tÏãJ 2lPSERVICE ADDRESS CONTACT PERSON LOCATION OF ASSEMBLY DOWNSTREAM PROCESS ÉeE Sffi{l.t NEW rNsrALL ú*,rr,*n E RrpucErv¡ENT El oLDsER. # REMARKS: PåSS*Ð N!pHoNE& 61L'noSS ,ort ) ocvn ,bl nran n PVBA D orHER- :--:- PROPER INSTALLATIONI VCS frO tr +E PREssuRE ØS ,r' CONFINED sPACE? [[C MAKE OF ASSEMBLY EL NO. INITIAT TEST P^SSED ú FAITED tr AIR GAP INSPECIION: Required minimum air gap separation provided? Yes E No E Detector Meter Reading M)"öl DCVA / RPBA CHECK VATVE NO.l uRr¡o El 3,0 ,r,, DCVA / RPBA CHECK VALVE NO.2 uer¡o E 3,L ,,,, RPBA OPENED AT- PSID #1 CHECK _PslD AIR GAP OK? - PVBA/SVBA AIR INLFT oPENED AT_PSrD oio r,¡or opr¡u tr NEW PARTS AND REPAIRS CI.EAN REPIACE PA¡T tr tr EI tr trn E EI CTEAN REPIAC€ PASI EI E EI tr tr tr tr tr CteAN R€PLACE PART tru n tr tr tr E¡ EI CHËCK VALVE HELD AT -PSID LEAKED E CLEANED REPAIRED u tr TEST AFTER REPAIRS PASSED tr FAILED E LEAKED tr PSID LEAKED tr __PStD OPENED AT-PSID #1 CHECK _PSID AIR INLET - PSID CHK VALVE PSID TESTERS SIGNATURE TESTERS NAME PRINTED: REPAIRED BYI CERT. NO. rEsrERs PHoNE "&S I 7<S -9Lrt iiINAL TEST SERVICE RESTORED? "' {*O ACALI Ntn CERT. NO. opproved test methads and test equipment' itw ù.tuúFdotu¡@ùtuúDù2úã BACKFLOW ASSEMBLY TESTER VALIDATIONCARD FOR CERTIFICATE OF COMPETENCY CERTIFICATE NUMBER VALID FOR YEAR BE IT KNOWN TEAT TIE WASIIINGTON STATE DEPÀRTIIilENT OF TIEALTII IIAS RDCOGNIZEI': 81253 2019 Marilyn E. Edlund AS A CERTIFIED BÁCKFLOW ASSEMBLY TESIER ,_) Gal i brati on Certifi cate Gustomer:Edlund Associates. lnc. Unit Under Test (UUTI Manufacturer: Mid-West Serial Number: 12121935 Model 845-5 Gauge Range:0-15 PSID Calibration lnformatlon callbration lnstrument: DP¡ 610 serlat Number: 61059948 N.l.S.T. Traceable Order Number 356281 Relative Humidity: Temperature: 42o/o 78 Fail Pass Pass Pass Pass Pass Pass Pass Pass Pass Permissible Deviation: 1+ or -) 0.2 PSID Prqcedures utllized were in accordance with the USC FCCCHR Mangal of Cross-Connection Control 1Oth Ed Appendix A and manufacturer's requirements. The remaining items in the test kít, if included (needle valves, hoses, etc.) were evaluated and pressure tested. Calibration Points 9 PSID 7 PSID 5 PSID 2 PSID 1 PSID As found Status As Left Status Date: 2/8/2019CertifiedGonéonat 7.O 1.0 o. 7580-A West Tennessee Strôet Tallahassee, Florída 32304 850-575-961 I Far850-575-6508 wwwbackflowparts.com