HomeMy WebLinkAbout1634659816_NWOutdoorandInteriorRenovations-701SunsetBlvdNE-Report-2021.pdfBackflows Northwest
BackfIom',No rthwesD 425-277-2888
12819 SE 38th St #57 ,11
. ity of
Bellevue, WA 98006
Backf low Prevention Assembly Test Report
ACCOUNT #
NAME OF PREMISE 701 Sunset Blvd NE
Return Report to: Mike Dotson
Public Works, Water Utility Division
1055 S. Grady Way, 51h Floor
Renton, WA 98057
(425) 430-7207 FAX (425) 430-7241
Commercial ❑ Residential ❑
SERVICE ADDRESS 701 Sunset Boulevard Northeast CITY Renton ZIP 98056
CONTACT PERSON
PHONE
LOCATION OF ASSEMBLY N side between neighbors along fence
FAX
DOWNSTREAM PROCESS Irrigatlonlrrigatlon DCVA IX RPBA ❑ PVBA OTHER
NEW INSTALL IBI EXISTING ❑ REPLACEMENT ❑ OLD SER. # PROPER INSTALLATION? YES 0 NO ❑
MAKE OF ASSEMBLY Febco MODEL 850 SERIAL N0. 73546 SIZE 1"
DCVA/RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
INITIAL
CHECK VALVE NO.1
CHECK VALVE NO.2
AIR INLET
TEST
OPENED AT PSID
OPENED AT PSID
LEAKED ❑
LEAKED ❑
#1CHECK PSID
PASSED ®
DID NOT OPEN ❑
FAILED ❑
2.4 PSID
2.0 PSID
AIR GAP OK?
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
NEW
❑ ❑
❑ ❑
❑ ❑
HELD AT PSID
PARTS
❑ ❑
❑ ❑
❑ ❑
LEAKED ❑
AND
❑ ❑
❑ ❑
❑ ❑
CLEANED ❑
REPAIRS
❑ ❑
❑ ❑ --
❑ ❑
REPAIRED ❑
TEST AFTER
REPAIRS
LEAKED ❑
LEAKED ❑
OPENED AT PSID
AIR INLET PSID
PASSED ❑
PSID
PSID
#1 CHECK PSID
CHK VALVE PSID
FAILED ❑
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Reading
REMARKS: High water pressure. LINE PRESSURE 110 PSI
TESTERS SIGNATURE:
CONFINED SPACE?
CERT. NO. B7159 DATE 09-17-21
TESTERS NAME PRINTED: Dennis van DOOrn TESTERS PHONE # 425-277-2888
REPAIRED BY:
FINAL TEST BY:
CALIBRATION DATE 08-16-21
DATE
CERT. NO.
DATE
GAUGE # 08210429 MODEL 845 SERVICE RESTORED? YES f81 NO ❑
1 certify that this report is accurate, and l have used WAC 246-290-490 approved test methods and test equipment.