336 ADMIRAL WAY (2).PDF13776
336 ADMIRAL WAY
f,
336 ADM I RAL WAY
(PORT)
�. CRITICAL AREAS CHECK
0- 0
ADDRESS:
TAX ACCOUNT/PARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
Ot
DISCRETIONARY PERMIT #'
lz--Zlq:,." -7197 DETERMINATION: []Conditional Waiver. Study Required Ej Waiver
al
- fo 2-5v
I 91-ow ?
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
,,, I �w
PERMITS (OTHER):. 61-bw\ MUZV(kdaii 4"4 "Yb ) Q;36-e�z&yd) dk(10
Q/ 1 5 012AP4:Q� q & 7 &-:�V-76w L�4� I q 2 6
eg& 1� lq?3,p/0 9 Z, Z.
PLANNING DATA CHECKLIST DATED: 1410-4 11 1
SCALED PLOT PLAN DA'
SEWER LID FEE $:
SHORTPLAT
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:-
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DA
OTHER:
LOT:
LID #:
BLOCK:
LATEMP\DS'rsTomis\Street File Checklist.doc
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PLANNING DATA .
New Commercial / Mulffamily Prooects
SITE ADDRESS: 3 3t, ZONING:
ALLOWED?:
USE(S) PROPOSED:
LEGAL NONCONFORMING LAND USE DtTERMINATIQN ISSUED (YIN)
CUP File: —To Allow What Uses?.
ADB FILE #:
PARKING: . M tKA^j4
Use:
No. Spaces Required:
. X
(floor area, # employees, etc.) =
Use:
No. Spaces Required:
X
(floor area, # employees, etc.) =
Use:
No. Spaces Required:
X
(floor area, # employees, etc.) =
Use:
No. Spaces Required:
X
(floor area, # employees, etc.)
Total Required:
Actual Provided:
SETBACKS: /A "�
.Required Setbacks:
Front: Left Side: —Right Side: Rear:
Actual Setbacks:
Front: . Left Side: Right Side: Rear:
Street map checked for additional setback required? (Yes/Noi)
MAXIMUM FLOOR AREA: lvd
Maximum Allowed: Actual:
BUILDING HEIGHT: 9,
Maximum Allowed: Actual Height:
Modulation Allowed?: Modulation Height:
Datum Point: Datum Elevation:
Elevato r Penthouse > 3 feet over height limit? If so,VAR#
LANDSCAPING: AA t,�
Matches ADB approved:
Bid Provided? Bond Amount (100% bid):
CRITICAL AREAS #:
SEPA DETERMINATION:-- P,,
SHORELINE REQUIRED?: :Zn - tj,,w W WA-i 1-7*3 - ote -2, 6.
Continued ...
1A1ibrary\AP1andatNewConun.doc
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DATE: P-e&- &. 1,7-4 PLAN CHK#, 0 4 - & 2-1
NAME OF BUILDING PERMIT APPLICANT:,
AAA km� A"4cv
PROJECT DESCRIPTION: "F2 Mptl-u
ADB FILE #: ORDATEWAIVED: jklilo-4- — A, _6pp44-,
PLANS MATCH APPROVED PLAN:
SUBDIVISION:
LOT AGGREGATION REQUIREW: —1vo
REDUCED SITE PLAN (8.5X11) PROVIDED FOR STREET FILE? A.,
OTHER:
Plan Review By:
V
1A1ibrary\^P1andatNewComm.doc
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MEEMMM���,�777 - -
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E,Ie Edit yiew insert Fgrmat Records Ipols window t!elp a -1
;u- r, h.�Ip
Favonit I e�'�`,J�qo; I
'41 z
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Critical, Areas
ID:
F3F9—'
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ATA#-.
PG_27 032-001 00
U ni"� IL Find
LSJ �J..
- Ik'
Revi".Nurhbet._
Date Received: 1_12/12/1996
Applicant: IPort
OWg NumbeF: r3-36,
ATI,
:SfteeU'�a.e.
34-014-00
32-001-00
We 1-1 Dic f ijite:
.7�
Int Sit' eeis:
Dete-FmDate: FI/-7/1997
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Detetminaii�n:
taf �.U&k
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.... ... . ...
Form View
FLTR NUM
Val
be Edit' yiew insert F2rmat &ecords lools WindDw me[p;,,,. T�
59
A� Z�
Z A
Pe rmit I D.
nning.Permits
111- 111a Tax Aect Ik jQqOO-000-000-00
Ne . Undo GoT T !Drm� f tW I E.CJ! 4�1
— — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Year: , App;% Type:
Applicant's Name: jEdmwds, �Ort Of
Building At F336
Street: lAd miral
Suffix F7 -3 Dir. f Apt At
am
intersection? rj-, street$:
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — I -J.-,:
Subdilvisio
ShowlProcess -i-M7
Permit Information..
— — — — — --- — — — — — — — — — — — — F — — — — — —
Description: IDemolish 0 dock, rebuild N 8 P
Date Rec'd: 01��
Hearing Me' fl 2/7/2000 lFinal Hearing:
'Decision: rApproved I Date.0'ecision Final- rl 1112001
�re F,;F Lj red) 1� . . . ....... J.
19 FLTR,' N4M,
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PLANNING DATA
New Commercial / Mulffamilv Proiects
SITE ADDRESS: 33 6a AA,-.v-K4 V4, ZONING: &W P_,). V,*C-
USE(S) PROPOSED: AL LOWED?: Ye4
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED— (Y/N)
CUP File: To Allow What Uses?:
ADB FILE #:
ow 644- fop�
PARKING: 0 K
Use:
No. Spaces Required:
I . X
(floor area, # employees, etc.)
Use:
No. Spaces Required:
X
(floor -area, # employees, -etc.)
Use:
No. Spaces Required:
X
(floor area, # employees, etc.)
Use:
No..Spaces Required:
X
(floor area, # employees, etc.)
Total Required:
Actual Provided:
SETBACKS: : Ajo c4v—jz
Required Setbacks:
Front: Left Side: Right Side: Rear:
Actual Setbacks:
Front: Left Side: -Right Side: 'Rear:
Street map checked for additional setback required? (Yes/No)
MAXIMUM FLOOR AREA:
Maximum Allowed: Actual:
BUILDING HEIGHT:
Maximum Allowed: -Actual Height,
Modulation Allowed?: Modulation Height:
Datum Point: Datum Elevation:
Elevator Penthouse > 3 feet over height limit? If so,VAR#
LANDSCAPING:
Matches ADB app=d:
Bid Provided? Bond Amount (100% bid):
CRITICAL AREAS #: 199 1- 4 8
SEPA DETERMINATION: QKS tea Z3 7,oz,
SHORELINE REQUIRED?: _�A- �M- Zmo- 9+ 6aamy,9LO - D-zAe— 1-1A N11PXA1
"9(-A5:-tr- ; red-tk 44 -,t C '' "D . f �.g ' j
Continued ... twk- saA an A) I VPY_ , 5 AO, 'po44A
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1AfibrWP1andatNewConun.doc P q VAk,
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DATE: )I -PLAN CHK#. 0
NAMEOF BUILDING PERMIT APPLICANT: oeg�
PROJECT DESCRIPTION: 041.i"IA, 0
I*'- P-Aif P,fq AAA h Al 2A A/ A-,," A- L-
A -f- 41%t N A- P NA-A64 Y
ADB FILE #: OR DATE WAIVED: 1441
PLANS MATCH APPROVED PLAN:
SUBDIVISION:,
z
LOT AGGREGATION REQUIRED?: 1W
REDUCED SITE PLAN (8.5XII) PROVIDED FOR STREET FILE? Ye,
OTHER:
ca Pian Review By:
lAlibrWPlandatN�wComm.doc
PLANNING DATA
New Commercial / Mulffamily?roiects
94 7
-]SITE ADDRESS: 336 Z-D -ZONING:
USE(S) PROPOSED: Doet� ALLOWED?:
LEGAL NONCONFORMING% LAND USE DETERMINATION ISSUED (Y"
CUP File: To Allow What Uses?:
ADB FILEM A
PARKING: M- (,"*e r9q wy4-A
Use: No. Spaces Required:
(floor area, # employees, etc.)
Use: No. Spaces Required:
X (floor area, # employees, etc.) =
Use: No. Spaces Required:
X (floor area, # employees, etc.) =
Use: No.Spaces Required:
X (floor area, # employees, etc.)
Total Required: Actual Provided -
SETBACKS: 94.,,, IVA
_.51
Required Setbacks:
Front: Left Side: -Right Side: Rear:
Actual Setbacks"
Front: Left Side: Right Side: 'Rear:
Street map checked for additional setback required? (Yes/No)
MAXIMUM FLOOR AREA: 9(-
Maximum Allowed: Actual:
BUILDING HEIGHT: mq
Maximum Allowed: Actual, Height:
Modulation Allowed?: Modulation Height:
Datum Point: Datum Elevation:
Elevator Penthouse > 3 feet over height limit? If so,VAR#
LANDSCAPING: lu C_
Matches ADB approved:
Bid Provided? Bond Amount (100% bid):
CRITICAL AREAS#: 19�2_ o/19 1996 -02�5b. bm-4, 14 t
SEPA DETERMINATION: A-mo�, rii-d R_/5' 10A I. rIt-3100
SHORELINE REQUIRED?: M41ft
— A, Pv� - A,*- A J'16 la4 /,�- 41e '5AI - AIM - 14- -
Continued ...
1A1ibrary\^P1andatNewComm.doc
DATE: ff/�-/o 4- —PLAN CHK#: 0 4 -219
NAME OF BUILDING PERMIT APPLICANT:. Par�` o� 9,o,�j
p
PROJECT DESCRIPTION: '#11_e*_ OWt—kf .4�1
ADB FILE #: !V14 OR DATE WAIVED: 91'�Io,4 - otAb
PLANS MATCH APPROVED PLAN:
SUBDIVISION:
LOT AGGREGATION REQUIRED?:
REDUCED SITE PLAN (8.5X1 1) PROVIDED FOR STREET FILE?
OTHER:
Plan Review By:
1Ahbrary\^P1andatNewComm.doc
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MEMORANDUM
Date: August 6, 2004
To: File SM-2000-94
From: . Meg Gruwell, Senior Planner ��
Subject: Dock Overlooks for Docks P, R, S and U
Shoreline Substantial Development Pen -nit file SM-2000-94 inv i
olved changes to P, R, S, and U
docks to improve tenant safety,'among the changes proposed with that project. The Port of
Edmonds has proposed constructing four. dock overlooks on those same docks as part of a project
being reviewed under Plan Check PC-04-319. The proposal cantilevers an expanded.deck in the
four locations towards the water, which will provide aplace for picnic tables, and for pe i
ople to
be out of the way of the flow of pedestrian traffic to observe activities in the marina. This
improves public access at the waterfront with a minimum impact to the natural ervirom-nent.
Each dock overlook is approximately 6 feet by 16 feet, or 96 square feet. With four dock
overlooks proposed, and an earlier "0" dock overlook of a. similar size, the total size is 480
square feet. This is within the allowable 500 square feet or 10 percent, whichever is less, that is
allowed through a permit revision per WAC 173-27400. The proposal is within the scope and
intent of the original permit, no height is changed, the proposal meets all the requirements of the
Edmonds Shoreline Master Program, no change is proposed to use or landscaping with this
permit, and no adverse environmental impact will be caused by the project revision.
The proposal for dock overlooks for P, R, S, and U is approved as shown on the attached plans.
. MICROFILM
City of Edm onds cQ Community Services
()V: ED'
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0
CITY OF EDMONDS
121 STH AVENUE NORTH, EDMONDS, WA 98020 (425) 771-0220
ADDENDUM TO EXISTING ENVIRONMENTAL DOCUMENT
Addendum to (check appropriate box) ' E(DNs L3 Eis L3 Other
Description of current proposal: Add four dock overlooks to docks P. R. S, and Q docks. Each dock
overlook is approximateiv 6 feet by 16 feet, and is cantilevered from the existing pedestrian walkw'ay.
I
Proponent: Port of Edmonds
Location of proposal, including street address if any: 336 Admira'l Way. Edmonds
Title of document being added to: Determination of Nonsignificance
Agency that prepared document being adopted: Port of Edmonds
Date document was issued:- Aunust 23, 2000
Addendum: —The above determination was made for an earlier proposal to reconfigure N-P docks and add
float extensions on G. and P-U docks. The current Droposal (City file Plan Check 04-319) is a small
addition with impacts in essentially the same areas and to considerably lesser degrees. Beca . use the
current pro*ect has limited environment a*l impacts and the impacts it would have would be not dissimilar to
the impacts of the larger pro6ect, the Determination of Nonsigniftance is seen as addressing all the
Pertinent environmental impacts on the site.
Name of agency making addendum: City of Edmonds
Contact person, if other than
responsible official: Meg Gruwell, Senior Planner -Phone: (425) 771-0220
Responsible official: Rob Chave
Position/Title: Planning Manager Phone: 425.771.0220
Address: 121 5 th Ave. N, Edmonds, WA 98020
MICROFILM
WAC (4115/98) CAFILMSEPMAddShomfinc.doc 9/6/04
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41-011
IL \ It \ A
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- Ed
J u I Z2. yuuq I : j 9 Fm' FND, INC
No, 0281 P. 14
UF EDMONDS 4257'eludei P. U4/0?
PUGET SOLNIC
eLLINGHAM
221A
CUNT %FERNON
PROJECT --low 00
trm n I -
EDMONDS
VATTLE
.1 T
TA06MAVICINITY
MAP LOCATION MAP
p OLYMPIA
NOt TO V_ALl SCAL91 15 - $00' IAPP$tOxj
EDUDIM LAT. 4r42-K LONG.
TIDAL INFORM&Uft
PUGCT SOM ULM HIGHER HIM WATER IMHHV6 alON
bgl!AM 1416k WATER WHV4 a V$w
utAN LOWZR LOW WA?tR %"Vkl a OAP
SOUTH MARINA
LOCATION
MID-M&All"
LVJL
kit 1.
=11 CXIST Mll
a] ANTHOM
I REST RANT
q@ iflulLs
A[ FAY
SITE PLAN
400 FT
______0 100 200
PROPOSM
qESS TO H-DOCK PORT OF EDMONDS RELOCATE EXISTING H-DOCK
GANCWAY
H-DOCK GANGWAY
IN- PUGET SOUND
0' M.L.L.W, AT- EDMONDS, WA-, SNOHOMISH
SCALt AS NOTED
COUNTY, SEC. 23. T27N, R3E
OPERTY OWNERS,
DMONDS APPLICATION 13Y-
Co. PORT 'OF EDMONDS PORT OF EDMONDS
336 ADMIRAL WAY
EDMONDS. WA, 98020 AWMT i of 3 DATE, JULY 1999
.4.
Jul-12. 2UU4 l:j9rm FND,INC
lid: et, EDMONPS
LE
No. 0281 P. 15
42Yn1w,:!dj, P. etwwe
Lauwp Pop" I
NEW $1x12' FLOAT
NEW PILI
CONSTRUCT NEW
RCLOCATE- EXISTING
CONCRETE PLATFORM
40' RAMP
REMOVE E!XISTING
CONCRETE
PLAN VIEW
40
a 6 10 20
PROPOSED-
1CCES TO K—DOCK PORT OF EDMONDS RELOCATE EXISTING H—DOCK
GANGWAY
H-DOCK GANGWAY
IN, PUGET SOUND
- AT, EDMONDS. WA., SNOHOMISH
0.0' M.L.L,W, SCAlf AS NOTO COUNTY, SEC, 23. T27N, RX
OPOWY OYMERS-
"EDMONDS APPLICATION BY -
IL CO. PORT OF EDMONDS PORT OF EDMOND5
336 ADMIRAL wAy
EDMONDS, WA. 98020 ISHM 2 of a IDATE, jAY 1999'
D
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iWA r
rty
Nuinb�r-. b6i 240,11,70 3 2 601 wax I
2
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�`3.' 1'1� Appr'0`X:'iMat6 Site Size Q,5%19NFqWff E&
(acres or square feet):
4..',.,. Isthis�-site�cjirretjtl devejopqd?.�)c- yes; no
Y
�z
If yes; how is site devOoped? bacck- 4
�5- Des
cribe the geim-al site topographv- Clieckall that I
app Y-
6-
Flat less�than-S-f over en e site.
Rolling: slopes on site gener�lly less than 15% (a vertical rise of 10-feet over a
of 664eet)-
Hillr- _sjopi�� present on site of more than 15% and less than 30% a vertical rise
of '10-feet o*v,e:r a horizontal distance of 33 to 66-feet).
Steep:. :gFA-es of greater -than 30% present on site (a vertical rise of 10-feet over a
horizontal distance of less than 33-feet).
—Other (please describe)::. k>u t Kmad is a� v. i ric c6^!2mqje
�Pp 4,
&I., 13abll% AL Q64�g�l� sbPed
ILS'
6. Sitt contai' "ar4eas"bf yeai-round sta��ing water. r-60 Approx. Depth:
7. Site contains areas of season standing 7rater-,... IA* Approx. Depth:
'What seas.on(s). of,the year?.
S. Site is *1n'-the:floodwia'y' o Of a' w, ate'r course.
9. Site -a,, -'creek or an area where vrAer flow . s across the grounds surface? Flows are year-
lou�d?.- YNO Flows a're , ieasonal? no (What time of year?
10. Site is primarily: fbrested meadow ;shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wed and is present on site: r%o
For City Staff Use Only
L Site- is Zoned?
2-. kS. inapped soil We(s)? —LA4;P.At4 L.104 14 V
3. Weiland inventory or CA. nup indicates wetland Present on site?
4;>. t-,Critical Areas inventory or C.A. inap indicates Critical Area on site?
5.. within* 'designated earth subsidehce landslide:hazard area?
6. Site: de miignated on the Environmentally Sensitive Areas Map? iet�l ETA
-DETERMINATION
',-7STUDYREOUIRED ......
WAT
VER
Re4wed'�y:
Planner
CONDrr[ONAL WAIVER
J /--7 NJ
.dat-,.
CA
N
8.90-19,
n% d
V
City of Edmonds'-,
M:�; "'Vo.
`k
'Imp ;I,
Is
Critical:- Areas',
I t 61; qc, �,Jjj, i
'ne Critical Areas Q6'cklist c—
ontainedon"'." ..'and. m6mii ft &,thj 'Me
this form is to be filled out by any person I review the checklist, make a precursoxy* site
preparing a Development permit rL. I - . 1, 'j., � 'I , 4!, 4
�patibhof the--,
Application for the City of Edmonai
prior.`,:�" "s uibsequ6ft steps n6cessaiy to complete a
toWs/hersubniitt.alofadevel,opment. devek"mtperinitapplicatioii�'-.-
permit to the City.
copy. of. this form',the..,
The purpose of the
sbould also submit a
_.apphcant
vicinity map
City staff to determine whet -her any* or plot plan for individual . lots
theparcd
potential Critical Areas ar'ie 6"' J wi cnoug�,detafl that City staff can find
r may be
present on the subject property.- lbe,
am-
information'needed fy subject parcd(s). Iii
to complete the t4e� applicant- shaH fd8tid,62
Checklist should be easily available from
.0ther p�!� infbrmation.-te�g.-tite'�)
obsemdons of the site or dati av2alabliif �lai;�UPOVIAOY 1. amp, k etc.) or studi
es In
5
City Hall (Critical Areas inventories, maps" bonj - ii;WG�R,;With this decklist t6
U
or soil surveys).
-st2ff in completing their -preliminary
assessmentof the site.
Anapplicant, or his/her representative,
must fill out the checklist, sign and date it,
.I have completed the attached Critical Area Checklist andattest that the answers 'provided are
ftctual, to the best of my knowledge (fill ou.t the appyopriate column below).
Owner I Applicant: ..Apprica
nt Re.presentative:
T6r-+ a-L Ectmord-c-
Le,.�. le, sac,�% a
Name
01 2q Mor 14,
7co
Street Address 4Zt.�f AAA
AV 7,
Earlylohcjs� WA -774-iQ54q
Secd4 W_. wA, q g lo3
ity, ta P
C ity, `Phon�
City, Statev,ZIP-
Xlaf�
Signature
tu re
'Y;
I M n Aa
-D ate
Sign atu&,, Date
JV-x
A�,
Mt
-A _)04 4,
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City of Eibnonds
Critical Areas
Checklist
7U Oftical &cas amift con� on
this f= is to be fiUW out. by any pawn
preparing a Dcvdop=t Permit
Applicatbm f" ft City of Edmonds prior
to hWher submittal, of a &welopment
permit to *e city.
11M Purpose of the Oweldist is to enab le
City staff to determine whether any
potential Critical Areas, are or may be
present on the subject Property. The
information needed to complac the
Checldist should be easily amlable from
i of die site or datit available at
City Hall (Critical An= invenwriM maps.
or soil surveys).
An applicant, or hi&%w,epe=fttive,
Iftuft fill out the checklist, sip and date it,
and submit it to the City. 7he city win
=ViCW the d=kft, UMkg a Pracm3ory sj
Visk and Make t-deb=nination of -ft
mfteqt=t step Mxessary to complete a
4r4d1opzn=t parojit application.
With it *med copy of this form, ft
should also submit a vicinity un
or pka plan for individual ' I parc
with cuoush detail that city. staff can find
and identify the subject parcel(s). In
-appflcant shall lndu&
addWon, the
:,other pertirieft Informflon (e-z-,site
plan, topoVmphy map, etc.) or studks I
conjunction with this Checklist to assW
staff In completift their.pMundnU7
of the site.
I have completed the anachad Critical Area Checidist and- attest that die answers Provided am
Wtual, to the beg of my imowledge (fill out the appmpriate column below).
Owner I Applicant: Applicant Repre-nntative:
PORT OF EDMONDS WILLIAM M. TOSKEY
Nam Name
Executive Director
336 ADMIRAL WAY
Stmet Addow
SUM Addmu
774-0549
EDMONDS, WASHINGTON 98020 J"
City, SUM, ZIP Phow
Phan.
S e p t��" 27, 1995
W111A - .. .
S*Mftm D" Sr
Da to
C
ATTACHMENT 5
File No. SM-95-130
0
CAF 0
4cpelt'ical Areas Che�klist
Site Information (soils/topography/hyd*rology/vetetadoxi)
1. Site AddressALDcaflon: Port of Edmonds
2. Property Tax Account Nun*a: .2 3 2 7 0 - 4 - 15 8 - 0 0 0 1
3. Approximse Site Size (acres or squam fft): 7 2 0 0 0
4. Is this site cuffently developed?
If yes; how is site developed?_ B o a t Y a r d
5. Describe the general site topogra0y. Check all -do apply.
x — Flat less than 54bet elevation chanxe ww entire site.
RolliW. 310M 02 SkO 900MY 1453 than 15% (a vertical risa of 10-feet ow a
horizontal din&nce of 664m).
Hilly: skqm presea on sM of m dian 15% md less.than 30% ( a vertical rise
of 10-fee over a hotbontal dista= of 33 to- 6&fm).
Steep: grades Of Me= than 30% PMSM an ske (a vertical rise of 10-ftet: mw a
horizonW distince of lea dm 33-fea).
- Other (please describe):
6. Site contains areas of year-round stauft wam. NONE Approx. Depth:
7. Sim connins areas of seasonal standing WSW. NONE AM=. Depth:
What season(s) of the yew?
S. Site IS in the floodway N / A floodplain of a Water 001irse.
9. Site contains a cruk Or an 3110a WhUD WdW ftm =M *9 Vou=ls =tsce? Flows am year-
rouncl?. Flows am seasonal? (Wba dzue of yew
10. Site is prinianly: fb ested meodkyw ; zhmbs Miked
urban landscapail Qmm,shrubs etc) R 0 C K Parking lot wi=—Very
11. Obvious wedand is present on site. NO . 1 imited landscaping.
50 Suffuse ___ F
qF
X� 7 8'
9w C00--__ -
3,
A 'ifty or'CA. mV indimmi wed�d,..
/VO
an ii�
-imp -Ye. 5 L,/;
:.�rw mweii9m or CA. bdmw Ciawd Am owwo
C*
. . .... . ....
7
-7-
r
I
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HLE
0 STRA
Critical Areas Checklist'
Site Information
Project Name: Permit Number
ALZ><4
Site Location: Ao,,, .,,PAL- JA14-1 Property Tax Account Number. Z3.2,I-Q31-r V
>/ -Cr60_S
Approximate Site Size (acres or square feet):
Have you filled out a Critical Areas Checklist for a project on this site before?
General Site Conditions
40
1. Has the site been cleared or logged? N.1h Date of most recent action: —
Soils I Topography
2. In the Snohomish County Soil Survey, what is the mapped soil type(s)? 47P 4RAA-3 L
13.1 Describe the general site topography. Check all that apply.
c-, Flat: less than 5 feet elevation change over entire site.
e4-c> Rolling: slopes on site generally less than 15% (a vertical rise of 10 feet over a
horizontal distance of 66 feet.)
N 0 Ifilly: slopes present on site of more than 15% and less d= 30% ( a vertical rise
of 10 feet of horizontal distance.)
Nc:�, Steep: grades of greAter than 30% present on site.
Comments 0,0 -r&,C uJAax-ra.04—
HydrologyNegetation
4. Site contains areas of year-round standing water Kc>
5. Site contains areas of seasonal standing water: N)t:> —Approx. Depth:
6. Site is in the floodway Kto floodplain
_1� c> of a water course.
7. Site.contains a creek or an area where water flows across the grounds surface? flows
are year-round? go Flows are seasonal? A3 n
8. Site is primarily: forested �,Yo meadow ;shrubs K�U ;mixed �0
9. Obvious wetland is present on site: tl� 0
10. Wetland inventory or map indicates wetland present on site: L�C>
11. Critical Areas inventory or map indicates an y Critical Area on site: r-) U*36,
.0
Tax -Account Number:
LEGAL OESCRIPTION
232703-4-014-0005
That portion of Government Lot 1, Section 23, Township 27N, Rangc'
3E further dcscribcd as
Beginning at the intersection of South-. Line Section 23 w . ith West
margin I of Admiral Wa Then N41048*00"E'alon'g said West mar
gin
..to Southwesterly margin of Dayton Str I eet; Then Northwesterly along
Southwtstcrly margin of Dayton Strec . t and' extention thereof to
Inner Harbor Line; Then'. S44059`30
"W along said Inner Harbor Line
to South Line Section 23; Ile.n Easterly along South Line Section 23
to Point,Of Beginning. -
Except for -the portion further desscribed as follows: Begin at
South
N89042VOW. , 728.09 ft to . the, True Point Of.
.1/4 Section Comer, Then
Beginning; Then N4.10418'00-E�,240".44 ft; Then N48012'00-W 116.�'2 ft;
Th ' cn S4V48'00"W160 ft; Then N64'047'00"W 31.3 ft; Then
S41*41*00"W 91.51. ft: Tben, S4.8012-00-E 123.7.2 ft to South Line of
Section 23; Then -S89042*00"E '30.18 ft to the True P . oint Of Beginning.
a
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Critical Areas. Checklist
Site Information
Port of Edmonds North Marinl�
Project Name: Breakwater Repair Permit Number:
3(a CIO "111 relL LAI
Site Location: Port of E monds Property Tax Account Number:
Approximate Site Size (acres orsiquare feet): 6,000 square feet
NIA
Eave you filled out a Critical Areas Checklist for a project on this site before? No
General- Site: Conditions
1. Has the site been cleared or logged? No Date of most recent action:.
Soils Topography
2. In the Snohomish:County Soil Survey, what i's the mapped soil type(S)? N/A:
3. Describe the general site topography. Check all that apply.
Flat: le ss than 5 feet elevation change over entire site.
Rolling: slopes on site generally less than 15% (a vertical rise of 10 feet ove.r a.
horizontal distance of.66 feet.)
Hill': slopes present on site of more than 15%. and lessthan 30% a vertical n—se
y
of 10 -feet of horizonial',distance.)
Steep.: grades of greater than 30% present on'site.'
Comments Ail workwould occur in the waters of Puget.Sound
Hydrology/Vegetation
4. Site contains areas of year-Tound standing water: Yes
5. 'Site contains areas of seasonal standing water: --.Approx. Depth:
6. Site is in the floodway floodplain of a water course.
7. Site contains abreek or an,area where water flows across the grounds surface? flows
are year-round? Flows are seasonal9
8. Site is primarily: foreste& ;rneadow shrubs _;mixed
9. Obvious wetland is present on site:
10. Wetland inventory or map indicates wetland present on site: Site is located"In Puget Sound
fA
W
& 9 0 . 19 9 -
City of Edmonds
Critical Areas Checklist
The Critical Areas Checklist contained on
this form is to be filled out by any inerson
preparing a Development Permit
Application for the City of Edmonds prior
to his/her submittal of a developm��"'t permit
to the City.
The purpose of the Checklist is to enable
City staff to determine whether any potential
Critical Areas are or may be present on the
subject property. The information needed to
complete the Checklist should be easily
available from observations of the site or
data available at City Hall (Critical Areas
inventories, maps, or soil surveys).
RSC rr-'VED
U t 17 1992
An applicant, or his/her representative, must
fill out the checklist, sign and date it, and
submit it to the City. The City will review
the checklist, make a precursory site visit,
and make a determination of the subsequent
steps necessary to complete a development
permit application.
With a signed copy of this form, the
applicant should also submit a vicinity map
of the parcel with enough detail that City
staff can find and identify the subject
parcel(s). In addition, the applicant is
encouraged to include any other pertinent
information or studies in conjunction with
this Checklist to assist staff in completing
their preliminary assessment of the site.
I have completed the attached Critical Area Checklist and attest that the answers provided are
factual, to the best of my knowledge (fill out the appropriate column below).
Owner / Applicant:
Bill Stevens/Port of Edmonds
Nwne
Port Manager
title
336 Admiral Way
Street Address
Edmonds, WA 98020 774-0549
City, State, ZIP Phone
7/14/92
Signature Date
Applicant Representative:
Jack Cox/CH2M HILL
Naine
Project Manager
Title
777 - 108th Avenue N. E.
Street Address
Bellevue, WA 98004 453-5000
City, State, ZIP Phone
7/14/92
Signature Date
IN
A.
,4
Critical Areas Checklist
Site Information (soils/t*graphy/hydrolofy/vegetafion)o
I Site Address/Location:
2- Property Tax Account Number: bolKWA :Ze 'j'70 3 - Z 601 Y.
3. Approximate Site Size (acres or square feet): ("LL
4. Is this site currently developed? 'i yes; _ no.
I
If yes; how is site developed? Ce,.nc, boc4�- di �f�ter slwx�f-�&
5. Describe the general site topography- Check all that apply.
X Flat- less than 5-feet elevation change over entire site.
Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a
horizontal distance of 66-feet)-
Hilly: slopes present on site of more than 15% and less than 30% ( a vertical rise
of 10-feet. over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a
horizontal distance of less than 33-feet).
I
1k Other (please describe):- rr<x.,�to. but KKt,�,d is a- I' i 5iope, cv-!am�jer
D,Nc�nc,L, V_r_,biA 'is. a 41!� -s(oaed
,?=L
6. Site contains areas of year-round standing water: r,�o Approx. Depth:
7. Site contains areas of seasonal sta�nding water: �N* Approx. Depth:
What season(s) of the year?
8. Site is in the floodway ro floodplain no of a water course.
9. Site contains a creek or an area where water flaws across the grounds surface? Flows are year-
round? . nV — Flows are seasonal? n c, (What time of year? Y
10. Site is primarily: forested ; meadow ;shrubs mixed
urban landscaped (lawn,shrubs etc) X'
11. Obvious wetland is present on site: r�o
For City Staff Use Only
1. Site is Zoned?
2. SCS mapped soil type(s)? 14
3. Wetland inventory or C.A. map indicates wetland present on site?
4.:- :-...Critical Axeas inventory or C.A. map indicates Critical Area on site?
5., 'Site within designated earth subsidence landslide hazard area?
6. Site designated on the Environmentally Sensitive Areas Map? 'IfTC:) — 4�p ETA ViM tx %
DETERMINATION
�`S_T.UDY REQUIRED — Seoewvilc.
VA .4,z"
WAIVER Alre"k,
Revie'wed by:�6
Planner
CONDITIONAL WAIVER
I 11 1�1, -
Vate
— , . A,1�,
P.CV01/04M4
Z)(AC AIC� Ajje_ re-,4AC-p- 0"q b- .0r
A�E- ClUtt Illk(0111 CaX% CAP
cl&.� 4 skudy 1 1-7
See- a._4�ed vxfcx-�.
0 0
9 0 - I
City of Edmon&
Critical Areas Checklist
The Critical Areas Checklist contained on
this form is to be filled out by any person
preparing a Development Permit
Application for the City of Edmonds prior
to his/her submittal of a development
permit to the City -
The purposeof the Checklist is to enable
City staff to determine whether any
potential Critical Areas are or may be
present on the subject property. The
information needed to complete the
Checklist should be easily available from
observations of the site or data available at
City Hall (Critical Areas inventories, maps,
or soil surveys).
An applicant, or his/her representative,
must fill out the checklist, sion and date it,
6
and submit it to the City. 'Me City will
review the checklist, make a precursory site
visit, and make a determination of the
subsequent steps necessary to complete a
development Permit application.
With, a signed copy of this form, the
applicantshould also submit a vicinity map
or plot plan for individual lots of the parcel
with enough detail that City staff can find
and identify the subject parcel(sy in
addition, the applicant shall include
other pertinent information (e.g. site
plan, topography map, etc.) or studies in
conjunction with this Checklist to assist
staff in completing their pr,61iminary
assessment of the site.
I have completed the attached Critical Area Checklist and attest that the answers provided are
factual, to the best of my knowledge (fill out the appropriate column below).
Owner I Applicant:
F6r+ nc-
Name
Actr,4 rod U),
Street Address
WA qqn2-c> -7 -1 q - t) t;(4a
CiIy,,StaVr*7-4f Phone
WE
Signature Date
Applicant Representative:
Les, Ila SQcio.
Na nw
q;tll Nfor44, 76K- S6re-L
Street Address
Secd4 te- WA, cl? 7Sq-Q9q(-,
City, State, ZIP Phone
6
Signature Date
CITY OF EDMONDS
CRITICAL AREAS RECONNAISSANCE REPORT
Site Location: 336 Admiral Way
Tax Acct. Numbers: 2627032001 XXXX,
(additional new address
27032300401400,
of 326 Admiral Way)
and 2327034158009
I
Determination: Study Required
Determination #: CRA-1996-250 (Updated)
Applicant: Steve Butterfield
Owner: Port of Edmonds
NOTE: THE ORIGINAL RECONNAISSANCE CONDUCTED FOR THIS PROPERTY ON
JANUARY 7,1997 DETERMINED THAT THE PROPERTY DID NOT CONTAIN ANY
CRITICAL AREAS AND A "WAIVER" FROM THE REQUIREMENT TO CONDUCT A STUDY
WAS ISSUED. HOWEVER, SINCE THE TIME OF THE ORIGINAL RECONNAISSANCE, IT
WAS DETERMINED THAT THE PROPERTY CONTAINS AND/OR IS ADJACENT TO A
SEISMIC HAZARD AREA. THEREFORE, THE ORIGINAL RECONNAISSANCE HAS BEEN
CHANGED, AND THE CURRENT CRITICAL AREAS DETERMINATION FOR THE
PROPERTY IS "STUDY REQUIRED" DUE TO THE PRESENCE OF A SEISMIC HAZARD
AREA.
CRITICAL AREAS RECONNAISSANCE REPORT: STUDY REQUIRED
During review and inspection of the subject site, it was found that the site contains and/or is
adjacent to critical areas, including a Seismic Hazard Area, pursuant to Chapters 23.40 and
23.80 of the Edmonds Community Development Code (ECDC).
GENERAL CRITICAL AREAS REPORT REQUIREMENTS
Critical Areas Reports identify, classify, and delineate any areas on or adjacent to the subject
property that may qualify as critical areas. They also assess these areas and identify any
potential impacts resulting from your specific development proposal. If a specific development
proposal results in an alteration to a critical area, the critical areas report will also contain a
mitigation plan. You have the option of completing the portion of the study that classifies and
delineates the critical areas and waiting until you have a specific development proposal to
complete the study. You may also choose to submit the entire study with your specific
development application.
Please review the minimum report requirements for all types of Critical Areas that are
listed in ECDC 23.40.090.D. There are additional report requirements for different types
of critical areas (see below).
Note that it is important for the report to be prepared by a qualified professional as
defined in the ordinance. There are options on how to complete a critical areas study,
and there is an approved list of consultants that you may choose from. You may contact
the Planning Division for more information.
General Mitigation Requirements for all Critical Areas are discussed in ECDC 23.40.110
through 23.40.140.
STUDY REQUIREMENT — SEISMIC HAZARD AREA
It appears that this property contains and/or is adjacent to a Seismic Hazard Area. Seismic
hazard areas are areas subject to severe risk of damage as a result of earthquake -induced
ground shaking, slope failure, settlement, soil liquefaction, lateral spreading, or surface faulting.
Settlement and soil liquefaction conditions occur in areas underlain by cohesionless, loose, or
soft -saturated soils of low density, typically in association with a shallow ground water table.
DEVELOPMENT PROPOSALS ASSOCIATED WITH SEISMIC HAZARD AREAS
Development within a Seismic Hazard Area must meet additional criteria.
A report by a licensed Geotechnical Engineer is required for applicable projects within
Seismic Hazard Areas. Note that it is important for the report to be prepared by a
qualified professional as defined in the ordinance.
0 Geotechnical reports within Seismic Hazard Areas must address liquefaction.
Report requirements are provided in ECDC 23.80.050 and more generally in ECDC
23.40.090.D.
Activities proposed to be located in seismic hazard areas shall meet the development
standards of ECDC 23.80.060.
ALLOWED ACTIVITIES
Certain activities are allowed in or near critical area buffers as specified in ECDC 23.40.20. If
you have any questions about whether your proposed development qualifies as an allowed
activity, please contact a Planner for more information.
EXEMPT DEVELOPMENT PROPOSALS
Certain development proposals may be exempt from Critical Areas Requirements (ECDC
23.40.230). If you think that a specific development proposal may be exempt, contact a
Planner for more information.
Machuaa. Planner December 18 2008
Name
Date
NOTE: Cited sections of the Edmonds Community Development Code (ECDC) can be found on
the City of Edmonds website at www.ci.edmonds.wa.us.
2
Jul.22, 2OU4 1:40PM
PND, INC
No, 0281 P. 17
CITY OF EDMONDS
121 M AVENUE NORTH - Edmonds. WA sam - (42s) 771-o22o - r-Ax (425) 771-0221
HEARING EXAMINER. I
FINDINGS, CONCLUSIONS AND DECISION
OF THE HEARING EXAMINER
CITY OF EDMONDS
IT: Port of Edmonds
GARY HAAKENSON
MAYOR
SM-2000-94
33 ) 6 Admiral WaY (See Exhibit A, Attachments I and 4).
[ON.- Shoreline Permit application for dock replacement (see Exhibit A,
Attachments 2 and 3),
R-OCESS: Shoreline Permit; Heari iiner conducts public hearing and
makes final decisiogr%:�40%
. X,
VES: TV&
a. Compliance witi&.LontS� %9 unity Development Code
(ECDC) Chapter
9 (SHORELINE MASTER
PROGRAM) 0
b. Compliance eith monds Community Development Code
(ECDC) Chapter 20.55 (SHORELINE PERMITS.),
Compliance with Edmonds Community Development Code
(ECDC) Chapter 20.100.010 (HEARING EXAMINER
PLANNIN,G ADVISORY BOARD AND
REVIEW). - CfTy COLNCIL
21F RECOMMENDATION AND'DECISION:
-mmendation:
:aminer Decision:
11ING:
Approve with conditions
Approve with conditions
file Ofticial file, which includeci plallnillg Division Staff Advisory Reporl,
,g the site, the Hearing Examiner cmducted a Public hearing on the application,
th�' Port of td.rnonds application was opened at 9:30 a.m., December 7, 2000, in
0
i u i - zz. zuuq j qu rm FND, INC No. 0281 P. 18
Hearing Examiner Decision
Case No. SM-2000-94
Page 2
the City Hall, -Edmonds, Washington, and closed at 9:47 am. Participants at the public hearing
and the exhibi6 offered and enteredare listed in this report, A verbatim recording of the hearing
is available in the Planning Division,
HEARING COMMENTS:
The following is -a summary of the comments offered at the public 'hearing.
From the City:
Steve Bullock, Project Planner, r�viewed the staff a�visory report and entered it into the
record (Exhibit A).
Arvilla Wde, Parks and Recreation Director, submitted Exhibit B and she said the
retention and maintenance of public waterfr6t access is essential to public recreational
needs. She spoke in favor Of recommended condition-� that was detailed in Attachment 4
to, Exhibit A.
Prom the Applicant:
Bill Toskey, Port of Edmonds, said the proposal would complete a project that began 4
Years ago following a major -snowstorrn. ife felt the proposal would have a positive
benefit on the environment, He responded to the concerns of the Parks and Recreation
Direct6r and said the proposed condition 3 is unrel'ated to the proposed project; the
proposed project is actually rbducing the demand for parking; the majority of the over 900
parking spaces on Port property *are available for public parking, and none of the existing
public. parking space's will be eliminated by the proposal.
From the Community: !t..
No one from the community attended the pub
I lic hearing.
PINDINGS OF FACT. AND CONCLUSIONS
4,- SITE DESCRIPTION
I. . Site Development And Zoning.,
a) Eacts:
(1) -Z-0-n-in-g: The zoning of the subject property is Commercial Waterfront (CW).
(2)!—x—iisfiinwa�n�d Pro osedDev�elom�ent, The site is currently developed with
the
Marina and its boat docks.
(3) lk�!��tation
Marina, The project area is entirely over water within the existing
b) Neighboring DevelOPment And Zoning:
(1) North West Sou and East: The Properties' are zoned and developed
under the CW standards.
Jul,22, 2U04 1:40FM PNDJNC
No. 0281 P. 19
Hearing ExaminerDecision
Case No. SM-2000-94
Page 3
�C.Onclusi0n: The Propos6d development would be consistent with the surrounding
zoning and development.
B. HISTORY
The Port has operated a marina in this area for many years. . In January of 199,6 a large
snowstorm hit the Edmonds community and all of the existing covered moorage buildings
except onecollapsed. The Port reconstructed all of the collapsed covered docks with new
ones with permits approved under File No. SM-1996-95' a*nd 147. Now that construction is
complete and the marina has a new configuration, the Port has decided to take the old "0"
dock out entirely and lengthen the slips on the docks on either side of the old "0" dock to
accommodate larger boats.
C. EDMONDS COMMITNITY DEVELOPMENT CODE (ECDC) COMPLIANCE
1. Zoning Standards for the Commercial Waterfront (CW') zo�e
a) Pacts:
(1) ECDd 16-55 allows for marine' -oriented services of which in water boat moorage is
considered.
b) LO_nclusion; The , Proposal coffiplies with the development standards for CW.
2. COMPliance with requiremeut for a Shoreline Pertnit
a) Facts..
(1) ECDC Section 15-36 identifies the proje�t area as an "Urban - Marine" shoreline
environnient,
(2) ECDC Section 15.38.020 identifies marinas as a permitted
Marine" environment e n the "Urban -
- This section also outlines the criteriausthat marinas must
comply with in order to be approved. These include:
L Open pile or floating dock construction shall be required.
2- Chemical or fuel handling and storage shall be inspected and approved by the
city of Edr.nonds, Marina operators shall be resporisible for safe handling of
such ffiaterial and shall be rtiquired to provide a means of handling any spills
that occur.
3. Marina design shall minimize danger to fish and shellfish resources.
4, Marinas shall be designed in a manner, which is aesthetica1ly compatible with
adjacent areas and will not prevent pedestrian access to Public shorelines.
5. Boats shall be prohibited from discharging chemicals, fuel or sewage.
(3) The applicant stated in Exhibit A, Attachment 2 the proposal meets these criteria,
(4) Staff agreed with the applicant's statements regarding how the proposed projec*t
meets the criteria for marinas (see Exhibit A),
J U 1. 2 2. 2QU4 1 : 4OFM PNO -, INC No, 0281 P, 20
Hearing Examiner Decision
Case No. SM-2000-94
Page 4
a) Conclusions:
(1) The proposed marina reconfiguration will be consistent with the shoreline
designation, policies and uses perr�itied wit -tun the City of Edmonds Shoreline
Master Program.
D. TECHNICAL COMMITTUE
a) Fact:
Arvilla Ohlde, Parks and Rec�eation. Director, §�oke at the hearing and submitted
Attachment 4 to Exhibit A and Exhibit B requesting that a condition be added to the
perm
i it,that reiterates conditions placed on previous Shoreline Pernlits.
b) Con�lusion:
There is no clear nexus between the proposal and the recommended condition, The
proposal will result in a reduction in the number of slips at the marim Therefore, the
need for parking will be reduced. Furthermore, sigl0icantly more parking is now
available than is called for in the Memo-Tandum of Understanding between the City
and the Port (Exhibit B) and none of the existing public access parking is proposed to
be removed. Therefore, the, conditionrecommended by the Parks and Recreation
Director should not be required.
DECISION
Based On the foregoing findings and conclusions, the -application is approved, subject to the
f011Owing conditions:
L The application is subject to the applicable requi . rements contained in the Edmonds
Community Development Code. It is -the responsibility of the applicant to ensure compliance
with the various provisiow in these ordinances.
2. The City shall not give construction authorization u til a minimum of 30 day r
approval. R s afte final City
I
Entered this 2 1 st day of December 2000, Pursu3-nt to the authority granted the Hearings Examiner
under Chapter 20. 100 of the Community Development Code of the City of Edmonds.
Ron McConnell, FAI p
Hearing Examiner
J U I ZZ. 2VU4 1 41 VM FND, INC No. 0281 P. 21
Hearing F-kartiner Decision
Case No SM-2000-94
Page 5
RECONSIDERATIONS AND APPEALS
The following is a surnmary of the deadlines and procedures for filing reconsideration's and
appeals. Any..person wishing to file or -respond to a recommendation, or appeal should
contact the Planning Department for further procedural wormation,
REQUEST FOR "CONSIDERATION
Section 20.100.010.G allows for the Hearing Exam'm-*er to reconsider his decision or
recommendation if a Written request is filed within ten (10) working days of the date of the
initial decision by any person who attends the public' hearing and signs the attendance register
and/or presents testimony or by any person holding an ownership inter�s't in a tract of land
which is the subject of such decision or recommendation. The reconsideration request'must.
c1te specific references to the findings and/or the criteria contained in the o"rdinances
governing the type of application being reviewed,
APPEALS
Section 20.105.020.A & B describe how appeals of a Hearing Examiner decision or
recornmendation shall be made, The appeal shall be made in writing, and shall include the
decision being Appealed along With the name of the Project and the date of the decision, the
name Of the individual or group appealing the decision, their interest in the matter, and
reasons why the appellant believes the decision to be wrong. The appeal must be filed vAth
the COIT'rnuriity Development Director within ten (10) working days aft�r the date of the
decision being appealed.
LAPSE OF APPROVAL
Section 20.05.020.0 states 'Unless'the owner obtains a building permit, or if no building is
required, substantially commences the use allowed within one year from the date of approval,
the conditional use permit shall expire and be null and void, unless the owner files an
aPPlication for an extension of the time before the expiration date.'
NOTICE To COUNTY ASSESSOR
The Property owner may as a result of the decision rendered by the Healing Examiner request
a change in the valuation of the Property by I
the Snohomish County Assessors Office.
EXHI]RITS:
rhe f011Owing exhibIts were offered and entered into the record.
A- Plaruling Division Advisory Report, with 4 attachments
-Excerpts from the Memorandum of Understanding between the City and the Port.
JU 1. z/. zuuq i : 4 1 rm M, INC
No. 0281 P. 22
PARTIES oF RECO"..
Bill Toskey
Port of Edmond-
miral Way
ds, WA 98020
�ring Division
partment
Recreation Division
Hearing Examiner Decision
Case No. SM-2000-94
Page 6
Gary Watters, PE
P,N&D, Inc.
811 First -Ave, Suite 260
Seattle, WA 981.04
Public Works Division
Planning -Division
Jukzz- ZVU4 1:JVFM VND,INC
C i i if EDMOMS.
0�0
Peratrovich, Nottingham & Dra
En)
No. 0281 P. 13
.4257711beedi P. avue
e, Inc..
Engineering Consultant's
sil MmtMenue, Sub 2$0-S9a1Ue,WA9a1o4- (2oo)624-1387- Fax (206) 624-13U*E-MaR, meilipridsea.corn
July 29, 1999
Attn: Mr. Jeff Wilson
City of Edmonds
Community Services Department
Edmonds, WA 98020
H-Dock Access Improvement Project
Shoreline Permit Revision
Shoreline Permit No. SM 96-147
Dcar Mr. Wilson:
PN&D 9844S.01
r(rz-ce,
D&WT
PN&D is transmitting the enclosed drawings for the proposed H-Dock ACCAMs Improvement
Project. Per your recommendations, the Pon of Edmonds is requesting a revision to the above
referenced shoreline permit. I
TU H-Dock Ac*ess Improvement Project involves the realignment of the existing accm
gangway serving H-Dock. The pmj= is necessary to improve safety and access during low tide.
cycles by improving head mom requirements. Key clemcrits comprising the project include the
following -
Existing uplands concrete pWorm will be demolished and replaced with an
approximately 12'x 12' new pile supported platform for fastening, the gangway.
A 8'x 12' concrete float extension will be added to the existing float to serve as a
landing for the realigned gangway.
Gangway and any utilities suspended underneath will be reloosted into its new
position.
Please call if you have any questions or need additional information.
and Drage, Inc -
,Gary Watters, F.E.
"Senior Engineer
Dill Toskey, Port of Edmonds
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PLIG-25-1999 10:04 CITTIW EDMONDS
4'�4 C. 1 10%)
CITY OF EDMONDS
No. 0281 -P. 11
42"10221 P.01/07
BARBARA FAHEY
I MAYOR
121 sTH AvENUE NORTH - EDMONDS, WA 98020 - (425) 771-OM - FAX (425) 771-0221
DEVELOPMENT SERVICES DqARTMENT
Planning - Building - Engineering
VM FAX (20"24-1388)
A" 1J.S. MAIL
August 24, 1999
Mr. Gwy Watters, P.E_
Perattovich. Nottingham and Drage, Inc-
s i i First Avenue� Suite 260
Seattle, WA 99104
Subject: REQUEST FOR AMEMMENTS TO APPROVED SHORFLRqE SUBSTANTLAL
DEV"PNEENT PERMU GRANTED UNDER CITY OF EDMONDS FME NO.
SM-96-147 FOR "H'DOCK ACCESS "ROVEMENT
Dear Mr. Watters;
I have completed my review of the Port of EAmonds requests to smend the approved Shoreline
Substantial Development Permit granud under File No. SM-96-147 to illm "IF Dock a=ss
improvements. Based on my review of yaw requed as outlined in your letter of July 23, 1999,
you have proposed to realign the existing gangway serving "Ir Dock to improve pedestdan
safety during low tide cycles. I ...
Upon my review and analysis Of Y0vr.feq'ugsU con4dered in accordance with the requirements
and provisions for a permit modification as stipulated in WAC 173-27-100, 1 have deternfined that
the proposed modifications are not comidered substantive and do not Materially alter the MOM
in a manner that i3 inconsistent vAth the terms and conditions of the pamit the 01MCr Pr08ram
and/or the policies and provisions of chapter 90.58 RCW, and therefore are approved as
specifically swed below-
"B" DOCK ACCESS MPROVEMENT PROJECT-
RMU Realignment of the existing acceSlIgangway serving H-Dock to
improve. aft and acceos during low tide cycles by improrVing head
room requirements. The key elemenu compfWng the project include
the following'.
Incorporated August 11, 2890
A r
bder CRY - Hekinan, Japan
Jul-22- 2UU4 1:39FM VND,INC
U EDMONDS
No. 0281 P. 12
42577im.- I P-02116(
a. Exisft - uplands. concrete platform will be demoUled jmd
replaced With an 8PPWi=At* 12-foot by 12-foot tww ple
supported platform for fasteidng the pngway.
b. A &fbot by 12-foot concrete Boat Werdion will. be added to the
c7dsting floet to serve as a landing for the realigned gangway.
c. Gangway -and any -utilitiei impended underneath will be relocated
into its new positiom
Dgjern� APPROVED Subject to the plau submitted on JUly 29, 1999,
with this revision request (see Enclosed).
If you have any questions� please do not heAtate to contact me at (425) 771-0223.
Sincerely,
Development SeMces Department - Plarming Divinic'n
Planning Supervisor
Enclosure 1. July 28, 1999, Letter fivm Gary Watters
City of Edmonds Receipt No. 13880
pc- File No. SM-96-147
Mayor Barbara Fahey
Scott Snyder, City Attorney
Rob Chaye,,Planruing Manager
Jeannine Cn-4 Building Official
W Bill Toskey, tx"tive Director Port ofEdmonds 336 Admiral Way Edmonds, WA
99020
Department of Ecology — Shorelands Division
Parties ofR*cord — File No. SM-96-147
FAP2d2
E RECEIVED
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N
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0 RESIDENTIAL
C OMMERCiAL,
MULTIFAMILY
0 PLUMBING / MECH.
I COMPLIANCE OR
CHANGE OF USE
SIGN
LOT COVERAGE
ALLOWED PROPOSED
IVA
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT LIRSIDE REAR
PARKING
REOD PROVIDED
LOT AREA
fILANNING REVIEWED- BY DATE
FENCE
REPA(k4'
GRADING
CYDS
( X FT)
DE OLISH
TANK
OTH
_o GARAGE
RETAINING WALL
F RE SPRINKLER
CARPORT
ROCKERY
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U E. SINE S OR ACTIVITY) EXPLAIN:
NUMBER. �., /
OF , S
STORIE
I NUMBER -OF.',-
:DWELL!"e-
UNITS"
CRITICAL
AREAS Fapw
NUMBE
DESCRIBE W8IRK TO BE DONE
W.I.L.n't
I IVA ell AAA OW rtee_,,.eA 04*-, Z- I Z4b2J
CHECKED BY
GROUP
SPECIAL INSPECTI . ON JAREA OCCUPANT
REQUIRED LOAD
YES
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REd 0 J3
V VALUATICIN
$
Description
FEE
Description
FEE
Plan Check
State, Surch4r9p,
HEAT SOURCE GLAZING %. LOT SLOPE.%
-Building Permit
City Surcharge
PLAN CHECK.NO; VESTED-DA.TE .
�Plumbing
Mechanical
THIS PERMIT AUTHORMES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t= BE DONE ON PRIVATE PROPERTY. ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS 'MARQUEES, ETC.) WILL REQUIRE
:Grading
SEPARATEPERMISSIOW
Engr. Review.
LU PiRM;rr APPLICATION:' 180 DAYS
IL PERMIT UMrP I YEAR - PROVIDED�WOFIK IS STARTED WITHIN 180 DAYS
E.n9r. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
to 'APPLICANT, ON BEHALF OF HIS OR: HER SPOUSE, HEIRS, ASSIGNS, AND SUCCE96RS
IN INTEREST, AGREES TOj INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
Fire Review
Plan Chk. Deposit
.
2 EDMONDS.. W.ASHINGTON4�!TS OFFICIALS, EMPLOYEES, AND AGENTS. FROM ANY AND.
Fire Inspection
Receip� # 7/
ALL CLAIMS FOR DAMAGES OF WHATEVER. NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE. OFTHIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMEDTO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
LandscapeInsp.
total Amt. Due
0
,I NOR LIMIT IN ANY WAY -THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN, IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. .1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC_
CALL
This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR,COD,E OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt Is lteknowlidged in space provided.
WORKMEA'S COMPENSATION INSURANCE AND RCW*18.27.
OF I IGNAJVRE DATE
6IGNAT04 (OWNER G DATE SI NED
IA95
A
771-0220.
/DATE
AfTE TION
M 1333
IT IS UNLAWFUL To USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL:
FINAL INSPECTION HAS BEEN MADEA.ND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION i09
PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
j.
RECEIVED
PERMIT EXPIRES
141A 7,6�A
CITY OF EDMONDS
USE ERMIT 7
ZONE
A"
NUMBER
Joe 8 #
CONSTRUCTION PERMIT APPLICATION
ADDRESS
/v
OWNER WLAME OF rO)INIESP
Ar
PLAT NAME/SUBDIVISION NO.
LOT NO.�
Llof.
I
.
lu
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L&JILING ADDRESS
3-7 �
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Pern9t Required
Reqd
.
EXISTING _� pFJOPOSer)
Street Uie Perailt
inspection Required
Sidewalk Required 13
CITY ZIP
ITELEPHONE
Ell 1*11) 4 0 U
WzS�- 77,If -0.54
REQUIRED DEDIC
urwerwound
wiring required El
NAME
Af#D f�?r
METER 61ZE
LINE SIZE
NO. OF FIXTIJRES
PRV REQUIRED
YES13 NO 13
Ix
Lu
x
0
ADDRESS
81/ Z6 0
A-1-el JI/e.
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP
TELEPHONE
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ICBL#
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ENGINEERING REVIEWED BY
� DATE
ADDRESS
0
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DATE
ILA
Zda :z
CITY ZIP
TELEPHO�E
U.
0
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[ANCE OF�CU
RELINE OR ADB#.
INSPECTION
REO'D
BOND
POSTED
STATE LICENSE NUMBER EXPIRATION DATE'
CHWKED BY
�=I_�4bYES
WO
$
M17 jdalage
SEPA REVIEW
SIGN AREA
HEIGHT
;I
�RRGF!ERTY TAX ACCOUNT PARCEL N9.
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LLJ1
8 z re U01oo
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ZMM E:] C9MPL ANCE OR
ADDITION ERCIAL A OF USE
XC CHANGE
IVA
z
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REMODEL. MULTIFAMILY SIGN
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LOT AREA
PLANNING REVIEWED BY DATE
A
_q� GRADING FENCE
If REPAIR E3
REMARKS
k-.f
CYDS X FT)
OTHER
DEMOLISH TANK
_,WALL F RE SPRINKLER
GARAGE RETAIN!Nr?
CARPORT �ROCKERY-'�. FIRE ALARM
0
-
(rYPE:OF USE 8 INESS OR-ACTIVrM EXPLAIN -
Awl 4 Cf.
CHECKED BY
F CONSTR_WTION
OCCUPANT
GROUP
NUMBER
.b F.,
NUMBER OF
DWELLING
N1
CRITICAL
AREAS
SPECIAL INSPECTIO
OCCUPANT
M
UNI TS
LOAD
0
STORIES
14
�UMBER
REQUIRED [3 YES
DESCRIBE WORK TO BE DONE. .
REMARKS
PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REG 'D
UA
Description
FEE
Description
FEE
Plan Check
State Surcharge�
HEAT SOURCE GLAZING % LOT SLOPE %
Building, Permit
City Surcharge
PLAN CHECK VESTED DATE
Plumbing.
TOO 5
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY ANY CONSTRUCTION OWTHE PUBLIC
Grading
: 2 DOMA114 (CURBS, SIDEWALKS; DRIVEWAYS; MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 DAYS
AL PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN i SO DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
"APPLICANt ON BEHALF OF HIS OR'HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
Lu IN.INTEREST. AGREES TO. INDEMNIFY. DEFEND. AND HOLD HARMLESS THE CITY OF
_j
a EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND.
Fire Inspection
Receipt #
'ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE .10F.'THIS PERMIT. . ISSUANCE, OF THIS PERMIT SHALL NOT BE
Insp.
DEEMED TO MODIFY; WAIVE.OR REDUCE ANY REQUIREMENT 00 ANY CITY ORDINANCE
Landscape
Total Amt. Due M5
x 0 NOR LIMIT IN ANY- WAY THE CITYS ABILITY TO ENFORCE'ANY ORDINANCE PROVISION.'L
___TR�eipt
Recording Fee
#
I HEREBY ACKNOWLEDGE THAT I HAVE -READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION
GIVEN L16 CORRECT, AND THAT I.AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPROVAL
THE OWNER. I AGREE TO COMPLYWITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Fees are paid, and
.IN VIOLATION OF THE LABOR CODE OF THE STATE.OF WASHINGTON RELATING. TO',
FOR INSPECTION
receipt . is acknowledged in space provided.
woRKMENIS C ENSATION INJURANCE.AND RCW 18.27.
0hp
OFFI Ls I D TE
SIGNATUR OR AG J[DATE OGNED
(42 5)
=ATU
.7711-0220
RE D BY JdATf
ATTEAT16k
EXT 13 33
IT IS UNLAWFUL TO USE OR OCCU . PY A BUI LDING OR STRU I CTURE UNTIL
.07
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-:
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
ORIGINAL - FILE - YELLOW - lNfSPEC R
eR
PINK -OWNER - GOLD -ASSESS R
04/02
PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
336 ADM I RAL WAY
(PORT)
BACKFLOW TEST 1 of 2
A()DRr--ss FILE -
ALL -33r* ADKIRA W-�l
isTRL #LE
RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
SEP 1 6, 1991
BACKFLOW DEVICE TEST REPORT UBLIC WORKS DEPT.
NAME OF PREMISES PO F &Jwow cls
SERVICE ADDRESS 33�, uja-vl A) -A
LOCATION OF DEVICE 141 D,,C k
DEVICE: wam - 200 1 / " 042--703-/
Manufacturer Model 'Tirze Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT ? - -�- LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGti --------
C1
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUVE
REMARKS: z t.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY 4Zg4,ja,"-1 OF Llk z e'zo'.� DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY 'OF DATE
1/73
RECEIVED
CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
SEP
199,
BACKFLOW
DEVICE TEST REPORT
PUBLIC WORKS DEPT.
NAME OF
PREMISES
A, v-71 of
EJ,,yo.,-jJg
SERVICE
ADDRESS 133
to Va L
m ou J -s tau.
LOCATION
OF DEVICE
bas
k
DEVICE:
t 1( )-a
=c
900
-/1170 9 o
Manufacturer
Fo—de-1— lize
Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE
DROP ACROSS FIRST CHECK VALVE
0 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO_2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
[I
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
D
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
_4
0
CLOSED T-IGHT -----
0
REDUCED PRESSUIFE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: /3. 11F- o i /; 7
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
11
1/73
RECIEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
SEP 1 6 199,
BACKFLOW DEVICE TEST REPORT WORKS DEPT.
NAME OF PREMISES P , c o,,tj J-c,
oyT
SERVICE ADDRESS L U)4,V
LOCATION OF DEVICE C
DEVICE: 220 7 ('9 9
F45—nufacturer "Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT 4::, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESS URT
2.
jf�
DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING ----------- 0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM— -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT-----
0
CLOSED TIGHT -----
0
REDUCED PRESSUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: C217
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY a-- DATE
FINAL TEST PERFORMED BY OF DATE
1/73
'RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENTSEP 16 1991
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS DEPT.
NAME OF PREMISES F F._/Im n -4
SERVICE ADDRESS 1 0 qA,1 , "
LOCATION OF DEVICE Do c. k
DEVICE: U1. 7t7
Flanufacturer —MoTeT— "Size Serial No.'
LINE PRESSURE AT TIME OF TEST — LBS.,
PRESSURE DROP ACROSS FIRST CHECK VALVE �4 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO..2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
.1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
jo
2. DID NOT OPEN
0
CLEANED
0
C LEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISCAPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
D I SC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------ :
0
SPRING --------------------------
0
P
PIN RETAINER ------
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT -------------
� 0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGtl --------
0
DIAPHRAGM - ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGTT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU F
REMARKS: I �
a
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 02J17
INITIAL TEST PERFORMED BY OF DATE 9-,j - 91
REPAIRED BY DATE
FINAL TEST PERFORMED BY 'OF —DATE
0
1/73
RECEIVED
CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
SEP 1 6 1991
BACKFLOW DEVICE TEST REPORT
UBLIC WORKS DEPT.
NAME OF PREMISES-
Po-e
oAjcfs
SERVICE ADDRESS
25144tio 141 C�.�
11)Aj
LOCATION OF DEVICE
DEVICE:
Manufacturer
Ro_� e I _tize
Serial No.
LINE PRESSURE AT TIME
OF TEST
LBS
PRESSURE DROP ACROSS
FIRST CHECK VALVE
9,zo LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
fif.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
C1
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT ------------- :
D
SEAT -------------
cl
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
o
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS:
r
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 811�F— 02-17
INITIAL TEST PERFORMED BY 4 4 0 1 E
DAT
REPAIRED BY DATE
FINAL TEST PERFORMED BY 'OF —DATE
11
1/73
RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
SEP 1 6 1991
BACKFLOW DEVICE TEST REPORT P BLIG WORKS DEPT!
NAME OF PREMISES A o F Ealm oAj 4 s
SERVICE ADDRESS kA 1r) F11A I , I J I
LOCATION OF DEVICE F
DEVICE: 90
Manufacturer Model lize Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE DROP
ACROSS
FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
A
REDUCED PRESSUIFE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
� 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGli --------
0
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
4241-
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 8VI 0117
INITIAL TEST PERFORMED BY f) L 0/
OF I-qa_ &j�m� DATE, 9-
REPAIRED BY DATE
FINAL TEST PERFORMED BY 'OF —DATE
0
1/73
RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
SEP 1 6 1991
BACKFLOW DEVICE TEST REPORT -----PUBLIC WORKS DEPT,
NAME OF PREMISES F
SERVICE ADDRESS v,,q L Lk) &IM 0 Al A.)
LOCATION OF DEVICE 62 Do k
DEVICE: . UJ67T-� 9,,-vo 11 / " —0 :�l -7n g-
Manufacturer Podel 'Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.,
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO..2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1 � OPENED AT 3- LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSUIFE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
[I
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
� D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -A -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --0
UPPER -------------------------
o
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 0217
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
I
1/73
RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT SEP 1 6 1,991
BACKFLOW DEVICE TEST REPORT UBLIC WORKS DEPT,
NAME OF PREMISES Mn V�—i —
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: WaTs
Manufacturer Zp eo - 91-5- 9
Model 'Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
0
CHECK VALVE NO..,2
1. LEAKED'
2. CLOSED TIGHT
0
A.
DIFFERENTIAL PR�SIURE RELIEF VALVE
1. OPENED AT - 3.y LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 13
DISC -------------
11
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
[I
rUIDE ------------
o
SPRING ---------------------------
0
P
PIN RETAINER --� ---
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
*
0
UPPER -------------------------
0
1
SEAT -------------
* 0
SEAT ---- ---------
0
LOWER --------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
5
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL
0 ENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS:
THE ABOVE.REPOIZ�TISICERTIFIED TO BE TRUE: 02-1�7
INITIAL TEST PERFORMED'BY OF
REPAIRED BY DATE
--DATE—
FINAL TEST PERFORMED BY OF DATE
1/73
0 0 RECEIVEL)
CITY OF EPMONDS PUBLIC WORKS DEPARTMENT SEP 1 6 199,
PUBLIC WORKS DEPT.
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES
SERVICE ADDRESS _� '�)^ a-1 A� , �'
F Fc-
LOCATION OF DEVICE _L 1_)o c- k
DEVICE: L� )a In 1900 0#'�_Zo'
. Manufacturer Fodel tize Serifl mo.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
0
CHECK VALVE NO...2
1. LEAKED
2. CLOSED TIGHT
0
A
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT 1-5— LBS.
REDUCED PRESSURE
2. DID NOT OPEN
cl
CLEANED
0
CLEANED
0
CLEANED
cl
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
c
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER --------------------------
0
1
SEAT --------------
D
SEAT -------------
0
LOWER --------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER,,DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
din
off It . I
0
CLOSED TIGHT -----
0
REDUCED PRESS
REMARKS: A �
/_ 02_1�7
THE ABOVE REPORT IS CERTIFIP TO BE TRUE: 6)��
INITIAL TEST PERFORMED BY 6"4 OF DATE 2-L 91
REPAIRED BY a-
---DATE—
FINAL TEST PERFORMED BY OF —DATE
il
1/73
RF.CEIVED
CITY OF EDMONDS
PUBLIC WORKS
DEPARTMENT
SEP 1 6 1991
BACKFLOW DEVICE TEST REPORT
PUBLIC WORKS DEPT,
NAME OF PRE141SES
A 0 F
SERVICE ADDRESS
a
L Ij In
EdIn
qu,�
c WAJ
LOCATION OF DEVICE
T j)o c
7—
DEVICE:
90r)
Manufacturer
Model
Tf-z e
Serial No'.
LINE PRESSURE AT TIME
OF TEST
LBS.
PRESSURE DROP ACROSS
FIRST CHECK VALVE
LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
CHECK VALVE NO...2
1. LEAKED
2. CLOSED TIGHT
DIFFERENTIAL PRESSURE RELI F VALVE
1. OPENED AT /,�/ LBS.
REDUCED PRESS
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
Disc -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
.P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT --------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
o
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT-----
[I
REDUCED PRESS-U-9-E
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 6j�7--0.217
INITIAL TEST PERFORMED BY..a1vj OF DATE
REPAIRED BY —DATE-
FINAL TEST PERFORMED BY OF DATE
1/73
0
0 RECEIVED
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT SEP lb 1921
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS DEPT.
NAME OF PRE141SES pn V,
SERVICE ADDRESS �R '�)_ )c;L/ " - .'
LOCATION OF DEVICE
DEVICE: Wa= — - L 042 2-11
Manufacturer Model '3ize Serial—tio.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 910 LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
1
0
CHECK VALVE NO..,2
1. LEAKED
2. CLOSED TIGHT
11
DIFFE'RENTIAL PRESSURE RELT F VALVE
1. OPENED AT LBS.
REDUCED —PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
13
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPR I NG -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
[I
rUIDE ------------ :
0
SPRING --------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
*
0
UPPER -------------------------
0
SEAT -------------
SEAT ---- ---------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL-
OPENED AT LBS.
TEST
CLOSED61GHT -----
'A
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 7-- o:7- 117
INITIAL TEST PERFORMED BY A Z
OF DATE
REPAIRED BY
FINAL TEST PERFORMED BY 0 . F -PATE
DATE
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT RECEIVED
BACKFLOW DEVICE TEST REPORT SEP I
PUBLIC WORKS DEPT.
NAME OF PRE141SES A j
SERVICE ADDRESS �� �" ) - , . - .'
LOCATION OF DEVICE
DEVICE: - wrl 7� - --- 90�_ 1,4 2 2-- / 9 17.41
Manufacturer Model - tize Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE DROP
ACROSS
FIRST CHECK VALVE
LBS.
INITIAL
TEST
—CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
0
CHECK VALVE NO...2
1. LEAKED 0
2. CLOSED TIGHT
9.
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT Ro LBS.
REDUCED PRESS
2. DID NOT OPEN
c:
CLEANED
0
CLEANED
11
CLEANED
c
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 13
DISC -------------
0
DISC.UPPER ----------------------
C
R
SPRING -----------
0
S P R I NG -----------
0
DISC. L014ER ----------------------
cl
E
GUIDE ------------
0
rUIDE -----------
0
SPRING --------------------------
C
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
*
0
UPPER -------------------------
0
1
SEAT --------------
[I
SEAT ---- ---------
0
LOWER -------------------------
0
R
DIAPHRAGH --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
110.
0
CLOSED TIGHT -----
0
REDUCED PRESS-UTE-
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: &�F- 0217
INITIAL TEST PERFORMED BY 1-4 _j OF DATE 9-j/-
REPAIRED BY —DATE
FINAL TEST PERFORMED BY OF —DATE-
13
1/73
REC;2:1
CITY OF EDMONDS PUBLIC WORKS DEPARTMEt&V 1 6 W-31
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES lin V�
SERV'ICE ADDRESS .� �21)1 A-11-i "'. I :
LOCATION OF DEVICE
DEVICE:
Manufacturer MoUel Size Serial No.
LINE PRESSURE AT TIME.OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE A0, LBS.
— —
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
0
CHECK VALVE NO.,2
1. LEAKED
2. CLOSED TIGHT
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT 2-0 LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEAUED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
Disc --------------
0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
[I
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PHI --------
0
HINGE -PIN --------
'
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT ---- ---------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
o
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
L_
CLOSED TIGHT -----
14,P)II
0
CLOSED TIGHT -----
[I
REDUCED PRESSUTE_
REMARKS:
THE ABOVE RE`P0`dT IS CERTIFIED TO BE TRUE: I&IF1
INITIAL TEST PERFORMED BY OF DATE 974/-.g/
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF —DATE
ij
1/73
0
RE CEIVED
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE:
Manufacturer
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT SEP 1 6 'ij�l
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS DEPT.
Do C
modeT— 'Size Serial f6o.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 9. # LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED ,
2. CLOSED TIGHT
1
0
—CHECK VALVE NO..,2
1. LEAKED
2. CLOSED TIGHT
0
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT /' & LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLAC . ED:
REPLACED:
Disc ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE -------------
0
rUIDE -----------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGf1 --------
0
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, L014ER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[I
REDUCED PRESSOUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY 0 F DA T E 9 —,/- 91
REPAIRED BY DATE 0
FINAL TEST PERFORMED BY OF DATE
I
1/73
CITY OF EDMONDS
PUBLIC WORKS DEPARTMENT
RECEIVED
BACKFLOW
DEVICE TEST REPORT
SEP 1 6 1991
NAME OF
PREMISES
Pov, I
o F F�dm �.C,
PUBLIC WORKS DEPT.
0 A/
SERVICE
ADDRESS
L
LOCATION
OF DEVICE
Do r-
C
DEVICE:
LDLL klilo'
2q L�6 h Le --dl-
— / L
Manufacturer
.
'Size
Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE
DROP ACROSS
FIRST CHECK VALVE
LBS.
CHECK VALVE No.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1.' OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSUVE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
C3
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-4 -------
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
L TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU F
REMARKS: V
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: )3#F- 0117
0 L
INITIAL TEST PERFORMED BY OF I DATE 9-3-91
REPAIRED BY --DATE—
FINAL TEST PERFORMED BY OF DATE
11
1/73
RECEIVED
CITY
OF EDMONDS
PUBLIC WORKS
DEPARTMENT SEP 1 6 1991
PUBLIC WOMS DEPT.
BACKFLOW
DEVICE TEST REPORT
NAME OF
PRE141SES
-0
SERVICE
ADDRESS 3310
/5�� \,^n
L
W_AJ
LOCATION
OF DEVICE AL
DEVICE:
250-.-
F
.2 1 00
Manufacturer
M— el-
_/0
'Size Serial No.
LINE PRESSURE
AT TIME OF TEST
LBS.
PRESSURE
DROP ACROSS FIRST
CHECK VALVE
LBS.
INITIAL
TEST
—CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
1
0
X
CHECK VALVE NO..,2
1. LEAKED
2. CLOSED TIGHT
0
DIFFERENTIAL PRtS�URE RELIEF VALVE
1. OPENED AT LBS.
REDUCED PRESSURE
2. DID NOT OPEN
c
CLEANED
0
CLEANED
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ------- * ---------------
c
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
C
E
GUIDE ------------
D
GUIDE -----------
[I
SPRING --------------------------
C
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
'
0
UPPER --------------------------
C
I
SEAT --------------
D
SEAT --- ---------
0
LOWER -------------------------
R
DIAPHRAGM --------
0
DIAPHRAGM --------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE �
0
OTHER, DESCRIBE --
0
UPPER -------------------------
cl
LOWER ---------------
13
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
- A A
0
CLOSED TIGHT -----
REDUCED PRESSUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 011-7
INITIAL TEST PERFORMED BY OF POL/ OZ4:!��/_DATE
REPAIRED BY --DATE—
FINAL TEST PERFORMED BY OF —DATE
1/73
RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMEN-GEP 1 6 1991
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS DEPT.
NAME OF PRE141SES A F Fr-)A4^ il-Ir
SERVICE ADDRESS A '�)' /--/-/ A A I �'
LOCATION OF DEVICE 7
s j'zlc a F /IrT o F17-ic't
DEVICE: Fe 6 co C - -d '77
Manufacturer Model �Size
SeriaT tio.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE DROP
ACROSS
FIRST CHECK VALVE
LBS.
INITIAL
TEST
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
I
0
CHECK VALVE NO...2-
1. LEAKED
2. CLOSED TIGHT
0
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT -9 -5- LBS.
REDUCED PRESSURE
2. DID NOT OPEN c
CLEANED
0
CLEANED
0
CLEANED c
REPLACED:
REPLACED:
REPLACED:
DISC -------------- 0
DISC -------------
0
DISC.UPPER ----------------------- C
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ---------------------- C
E
GUIDE ------------
0
rUIDE ------------
0
SPRING -------------------------- C
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN ---------
0
HINGE -PIN --------
*
0
UPPER ------------------------- C
I
SEAT --------------
D
SEAT ---- ---------
0
LOWER ------------------------- C
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER ------------------------- C
LOWER --------------- c
SPACER,,LO14ER -
OTHE.R, DESCRIBE
FINAL
TEST
CLOSED TIGHT -----
A "a
0
CLOSED TIGHT -----
0
OPENED AT LBS.
REDUCED PRESSOUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF ----DATE_Y-_ -9/
REPAIRED BY u DATE
FINAL TEST PERFORMED BY — OF DATE
13
1/73
NAME OF PREMISES
000MIE1 RECEIVlEt)
CITY OF EDMONDS -.- PUBLIC WORKS DEPARTMENt EP 12
BACKFLOW DEVICE TEST REPORT UBLIC WORKS
m
SERVICE ADDRESS nto uiv gs/0
LOCATION OF DEVICE Goo� ---Doc k
DEVICE:
Ranufacturer MoTel Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT X.
REDUCED PRESSUFE
2. DID NOT
OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------ 0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIE)? TO BE TRUE:
INITIAL TEST PERFORMED BY OF _,10od wl DATE 996
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
i 'I -i 6
A-
0.- STREE 11 t- Lft RECEIVED
CITY OF EDMONDS PUBLIC WORKS DEPARTMEN �E?
PUBLIC WORKS
BACKFLOW DEVICE TEST REPORT
p
c
NAME OF PREMISES V�f CF
SERVICE ADDRESS 1 ct 9 uj.Ajf 9kolo
LOCATION OF DEVICE Doc Ll"
DEVICE: 900 Z.
14-anufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2, L LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSUFE-
2. D 1 0 NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM - ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED*TIGHT -----
[I
REDUCED PRESSU
REMARKS: 2L L.=ugs;'g� q - 1.1 .9, 12pv
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: J3171TO9 J7
INITIAL TEST PERFORMED BYet,4 S. Vtfl�, DATE
OF
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
I
1 170
0 - . STREET FILE 0 R E C E'I'V-Et)
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT SEP 12 mu
PUBLIC WORKS
BACKFLOW DEVICE TEST REPORT
NAME OF
PREMISES
PovT oF
SERVICE
ADDRESS
In 0/l/M I'VrA
/J r
LOCATION OF DEVICE _F
77
�Ir pe) yji ())=F)e r- 1,A) M,,44.
DEVICE:
--D.6 // - 2. s _6 - - T — /000 5-L
Manufacturer go -del Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
11. OPENED AT LBS.
TEST
2. CLOSED TIGHT
)<
2. CLOSED TIGHT
?4-./
REDUCED PRESSUR
;N -
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFgD TO _BE TRUE: 611T o217
INITIAL TEST PERFORMED BY OF 00� j.q/ DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF _1DATE
v
i p � t%
0 - . STF(EET fift RECEIV'ED
C I TY OF EDMONDS -.- PUBL I C WORKS DEPARTMENT SEP 12 MU
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS
NAME OF PRE141SES 1--'n v- / o
SERVICE ADDRESS � 3 L, Y.4� 'v�a L / j P-c(m n,, jeJ c /,/ )A I -
LOCATION OF DEVICE A4
DEVICE: Fe 0
Manufacturer —Mo-de-f Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1.
LEAKED
0
1. OPENED AT .2-1 2-- L 8 S .
TEST
2. CLOSED TIGHT
x
2.
CLOSED TIGHT
LJ
^-
REDUCED PRESSURE
2. DID NOT
OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE --------- ---
11
AUIDE ------------
0
SPRING --------------------------
0
P
PIN,RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURY
REMARKS: a ,,,
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 13h'T 0117
INITIAL TEST PERFORMED BY �"., j. OF (qj-,,ajjj?4 DATE 9-17- 90
REPAIRED BY a DATE
FINAL TEST PERFORMED BY OF DATE
0
1 -170
o'.
STREEA:1LE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Pc v--F a F
RECEIVED
SEP 121990
PUBLIC VVORKS
SERVICE ADDRESS \/,a L Lon P-JI" 0 'dZ 9�-o �- o
LOCATION OF DEVICE
DEVICE: Wn 9109
d—eT—
Manufacturer Mo Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE q* LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
9.
REDUCED PRESSURE
'k
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
[I
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
� 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS:
:71
THE ABOVE REPORT IS CERTIFIKD TO BE TRUE: &17 o2-1�7
INITIAL TEST PERFORMED BY
-onA OF —&d�x &IemovZ� DATE 9-17- Vo
REPAIRED BY . J DATE
FINAL TEST PERFORMED BY OF DATE
0
It I -In
STREET FILE* RECE1'VED
CITY OF EDMONDS PUBLIC WORKS . DEPARTMENTS&
BACKFLOW DEVICE TEST REPORT PUBLIC \NORKS
NAME OF PREMISES 0,,7- ri F FLY) n A I
SERVICE ADDRESS 92,m , V'�ct L o L/ , , j � v ) �
LOCATION OF DEVICE I- /-), , k -
DEVICE: � ) 1�00 /
Manufacturer 9-odel Size Serial No. -
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1.
LEAKED
0
1. OPENED AT Z- 2— LBS.
TEST
2. CLOSED TIGHT
2.
CLOSED TIGHT
y
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
: 0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS: Lvw
.� 4 -is -9-0 1
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: BAIF02-17
OF �') I e� (�� DATE R,-)-,7- 90
INITIAL TEST PERFORMED BY enz
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
STREET FILE 0
RECEIV'ED
CITY OF EDMONDS -.- PUBLIC WORKS DEPARTMENT Z'1990
BACKFLOW DEVICE TEST REPORT pUBUG WORKS
NAME OF PREMISES t J10 VIT
SERVICE ADDRESS 33 tp V_a. L ��'M'6'jd ( u), i ,
LOCATION OF DEVICE T b, c
k
DEVICE: Wa TR
.900
03L�209
Manufacturer
Model
Size
Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 9-111 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
ly/
2. CLOSED TIGHT
-21.3
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
OISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------ 0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[I
REDUCED PRESSUTE-
REMARKS: 2 4-12,90 ck & /�
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 02-)
INITIAL TEST PERFORMED BY OF (0 DATE
d
REPAIRED BY P DATE
FINAL TEST PERFORMED BY OF —DATE
il
NAME OF PREMISES
0 STREET FILE
CITY Of EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
-VA
RECEIVED
SEP 12 158U
PUBLIC WORKS
SERVICE ADDRESS 3.��o ,�Ivm�aL 111,--v F�1m,,.4Jc 1j)v,
LOCATION OF DEVICE L)or- k
DEVICE: (-)),q 7� .2010 / v 0#17 2_//
Manufacturer Model Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED'
0
1. LEAKED
0
1. OPENED AT 2 ' I LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ------------------- ---
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE -_
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
�SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU F
REMARKS: 62,00,b 9_1_7 -3b _61.� 1gop
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 6/1�r 0�j7
INITIAL* TEST PERFORMED BY 'I" ,^J A OF Po,�, ZZ DATE 9 -2�7-90
0
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
I 'I -mv A
STREET. FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS A'2, 41 ,Z /,.'
RECEIV'ED
SEP 12 Mu
PUBLIC �VORKS
L�L��, A -1
LOCATION OF DEVICE
DEVICE: �oo
&IJ ZQ 3?,
Manufacturer Moael 'Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT I'tp LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT.
)(.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
' Disc -------------
13
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------ ;
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N ---------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER ------------------- ------
0
LOWER -----------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSEDJIGHT -----
0
REDUCED PRESSUIFE
REMARKS:- go A
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF ---DATE
0
1/73
STREDWILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT RECEIVED
BACKFLOW DEVICE TEST REPORT SEP 12 Wu
NAME OF PREMISES 0(%) v n F-rltl)A tl -4 J PUBLIC WORKS
SERVICE ADDRESS 33to e��,,Lrq L fdVM0A1c_1S U-)AI, 9k0i 6
LOCATION OF DEVICE M L)c7c
DEVICE: 22 960 zo
urer' —Mo FeT_ Tize Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 9�L LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2-11 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
D
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUTE_
REMARKS: 211, c1h= Ps q - .a .2Q OYL 00 J/
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 61�17_ 021Z
"() I
INITIAL TEST PERFORMED BY OF r DATE
6 � 1. L o/ ?, �1
REPAIRED BY —DATE
FINAL TEST PERFORMED BY OF —DATE
I
0 STREET FILE 0 �ZECEVV'Et)
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT SEP 10�u
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS
NAME OF
PRE141SES
Ao) 0
F' EdA, OA) dO
SERVICE
ADDRESS
LOCATION OF DEVICE LQc. L
DEVICE: U )cL'__lR_ _Soc) 01-1 Z11 .: zo_ 9 3
Manufacturer —Mo-cFe—1 Size SeriAl No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
- -
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
1.
LEAKED
0
1. OPENED AT Z- �Z__ LBS.
TEST
2. CLOSED TIGHT
.0
2.
CLOSED TIGHT
X.
REDUCED PRE-SSURE
2.
DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED .
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
[I
DISC.UPPER ----------------------
o
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
o
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS: 9-� cv, 1�<"o
'Fo
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: _�_ / -7
INITIAL TEST PERFORMED BY OF o/ DATE Q�/-
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STNET F ILE aECEIVIE'O
CITY OF EDMONDS PUBLIC WORKS DEPARTME
BACKFLOW DEVICE TEST REPORT SEP 12 199U
NAME OF PREMISES P', V'7 (3 F ie��V-m o'v � _� PUBLIC WORKS
SERVICE ADDRESS _q ��/' "
77A
LOCATION OF DEVICE /�7
DEVICE: Wo 71�'
Ra-nufacturer No-d e I Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 11716- LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
13
1. OPENED AT 3, V LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X.
REDUCED PRESSUVE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM - ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS:
� q -,g - 9,, ell
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 617IF021Y
INITIAL TEST P ERFORMED BY OF DATE 20
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF —DATE
a
i I *In
0. 0
STREET 51LE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
RECEIVED
SEP 12189U
PUBLIC WORKS
SERVICE ADDRESS 3-1 to /Zvmi oa L — 1--d11"0Aaq (1),11,
LOCATION OF DEVICE 0 c 1"
DEVICE: 11 )a, IT. 900 0417-097
Manufacturer -Mo-a-el— Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE �' 61 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
1. LEAKED
0
1. OPENED AT 1-- 3 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
)4.
REDUCED PRESSUKE
2.
DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
� 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU F
REMARKS: Z a"., �& P
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:'6 /�T o2- j -7
INITIAL TEST PERFORMED BY OF Pbvd o/ &&,c�. DATE 5?0
REPAIRED BY
DATE
FINAL TEST PERFORMED BY OF DATE
a
I / 7.Q
0 STREET FILE 0
RECEIVE10
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
SEP 121WU
BAC,KFLOW DEVICE TEST REPORT PUBLIC WORKS
NAME OF PRE141SES
SERVICE ADDRESS 3,3
LOCATION OF DEVICE pn C_ 1v
DEVICE: tj )o_-TT�
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 91 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2 " �Z LBS.
TEST
2. CLOSED TIGHT
')4
2. CLOSED TIGHT
X.
REDUCED PRESSURT
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------ 0
AUIDE ------------
0
SPRING ---------- : ----------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
I
SEAT ------------- :
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT-
0
CLOSED TIGHT -----
0
REDUCED PRESSUIFE
REMARKS:
THE ABOVE REPORT IS CERTIFIED 'TO BE TRUE: -,7
INITIAL TEST PERFORMED BY a�ojjj
OF )omf. DATE g-)-2-90
REPAIRED BY
DATE
FINAL TEST PERFORMED BY OF —DATE
11
,I I -p n
@rREET FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTAMEIVED
BACKFLOW DEVICE TEST REPORT SEP 12199U
NAME OF PREMISES fDov,,T PUBLIC WORKS
SERVICE ADDRESS I? A In
d 11 Or, FdP'�l 17,VCk' 1J).4), 9kn ) /3
LOCATION OF DEVICE -0, br7r_ k
DEVICE: ____F - 1
12 DZ11 7, o 9
er Model— Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE C/; 0 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1.
LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2.
CLOSED TIGHT
K
REDUCED PRESSUIFE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
C]
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 010
INITIAL TEST PERFORMED BY OF PK),l ol DATE 9-1:�-c
REPAIRED BY
DATE
FINAL TEST PERFORMED BY OF.
DATE
1 -1 IT 6
FILE
CITY OF ESTN91�9ULIC WORKS DEPARTMENT
SEP 12 ISSU
BACKFLOW DEVICE TEST REPORT PUBLIC WORKS
NAME OF
PREMISES
Pov�F a F Fe4v"aalck
SERVICE
ADDRESS
LOCATION OF DEVICE
DEVICE: 1)), M � 219 0 o 9 /9
Manufacturer Mod�l Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE Lo LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELTEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT 4,65, LBS.
TEST
2. CLOSED TIGHT
NO
2. CLOSED TIGHT
REDUCED PRESSURE
/ON
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
.REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
13
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED T-IGHT -----
0
REDUCED PRESSU F
REMARKS:
") -1^6 -
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: j�T 0117
INITIAL TEST PERFORMED, BY OF DATE 8`17JO
REPAIRED BY DATE_
FINAL TEST*PERFORMED BY OF -DATE
I
'I i '7
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
RECEiVED
BACKFLOW DEVICE TEST REPORT
s -2 OU
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICI
DEVICE: Lj_)_0'7� - 200 0.�/Izgw/
Manufacturer Model Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
- -
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT 14 LBS.
TEST
2. CLOSED TIGHT
A
2. CLOSED TIGHT
REDUCED PRESSUWE
2. DID
/K
NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
Disc -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------ :
0
SPRING ----- ----------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
11
DIAPHRAGM, CiEC
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE --
0
OTHER, DESCRIBE _-
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
I
0
CLOSED TIGHT -----
I
[I
REDUCED PRESSURE
REMARKS: c_ lt&j� 0) 90
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 02
INITIAL TEST PERFORMED BY OF Paj �Z DATE Z-1 �7- 90
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
NAME OF PRE141SES
SERVICE ADDRESS
LOCATION OF DEVICE
0
STREET
FILE
it
CITY OF
EDMONDS -- PUBLIC
WORKS
DEPARTMENT
BACKFLOW DEVICE
TEST R-EPORT
OF "1:J"n0'u'Z
DEVICE: . Uj 0-:77 900 0 6/2 �j g-1
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2,Zo LBS.
.,TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
)2(.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N ---------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM --------
c]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE _-
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: (3//T-02-/7
INITIAL TEST PERFORMED BY OF DATE 10 -9'9
REPAIRED BY 7 DATE
FINAL TEST PERFORMED BY OF _1DATE
1/73
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Poy,7-- o .2:144 o,,-1 ol s
SERVICE ADDRESS 33 L scr, L t4)�_jl
LOCATION OF DEVICE
DEVICE: � j j ; 0.4�2 Zo 20
Manufacturer Ro-del Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 6-1 � LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
0
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
.
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
C1
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE _-0
UPPER -------------------------
0
LOWER ---------------
cl
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[3
REDUCED PRESSURE
FA
eVEAl'
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 6p__ 02,17
INITIAL TEST PERFORMED BY OF -DATE X-)o-g�
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES Ho v-
SERVICE ADDRESS 2,3(, 'Z2,Q' i'v" a
LOCATION OF DEVICE C D, 0� k/
DEVICE: . U)o, �11 7o 9
Manufacturer TFodel Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3-0 LBS.
TEST
2. CLOSED TIGHT
)19
2.' CLOSED TIGHT
0.
REDUCED PRESSURY
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
CUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE _- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: I'Momom ow'), llffm
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 13�IF-C 2_17
INITIAL TEST PERFORMED BY �0'� .1 . OF DATE E'—Jo —.ff
REPAIRED BY 0 DATE
FINAL TEST PERFORMED BY OF
I
1/73
CITY OF-EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAMEOF PRE141SES Y, T_ n F 'F14 AYIQAI�s
SERVICE ADDRESS 3 3 L z92'_,-w , �
LOCATION OF DEVICE p bar le
DEVICE: . u)0-m go()
Manufacturer Fovel Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2-�o LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
A.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
I
SEAT -------------
* []
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE _-0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED -TIGHT -----
0
REDUCED PRESSU F
0 a ;o va
11=0400310 WE
THE ABOVE REPORT IS CERTIFI�p TO BE: TRUE:
INITIAL TEST PERFORMED BY P,&�hj (' ",
OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
0
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Po n —1, o F f-J m ou J, s
SERVICE ADDRESS '-� ), I -
LOCATION OF DEVICE
DEVICE: . ('00-TFS 9c) 0 0 // )-7o tf
Manufacturer Model Size -S —er—i—aT I —10
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 21/ LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2--4 LBS.
TEST
2 CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
A
0
REDUCED PRESSURE
REMARKS: fieAa�z 9-2929 ZZZ-
THE.ABOVE REPORT IS CERTIFIED TO BE TRUE:
-0 7 V
agVL,
INITIAL TEST PERFORMED BY OF DATE 9-/p-9,J
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
pLfi:�
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES
SERVICE ADDRESS 3 3 (o L
LOCATION OF DEVICE L
DEVICE: . ( 'Of, M 5_�o_ a
Manufacturer —MoTel— Size Serial- N-0.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE //.o LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
11
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
fi�
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE _-
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[I
REDUCED PRESSURE
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:8//F- 01/7
INITIAL TEST PERFORMED BY OF DATE 9/-/0-9'2
REPAIRED BY --DATE
FINAL TEST PERFORMED BY OF -DATE
I
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES No r ) o F Fc-
SERVICE ADDRESS N4,
/ f
LOCATION OF DEVICE
DEVICE: 00- 7T 9on
Manufacturer �—od-el Size —Se—r i—a- F —fl o
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT /, �( LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
0.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER* ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
* 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
El
DIAPHRAGM — ------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
�'Z;o wl*wflo IvInNAWNER
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: —01/7
INITIAL TEST PERFORMED BY
OF
REPAIRED BY
FINAL TEST PERFORMED BY OF
PoJ 0,/ &tm-o� DATE Rl—/O-
DATE
DATE
il
1/73
NAME OF PREMISES
SERVICE
LOCATION
DEVICE:
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
E-1
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST.
2. CLOSED TIGHT.
Id
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
11
SEAT -------------
11
LOWER --------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
c]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -----------------------
o'
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED-f-IGHT -----
0
REDUCED PRESSURE
REMARKS 99
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF Pad o/ (Ojm,6� DATE k-lo-�-2—
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES ion v17— nF
SERVICE ADDRESS
LOCATION OF DEVICE
1;71
DEVICE: Fe � co
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT 2.3 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
V
REDUCED PRESSUW—E
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
.
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
CLOSED TIGHT -----
0
REDUCED PRESSU
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 8,,yT- 011 '7 y) 0-
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES -Ho vT- o F E-Jvncv d
V,
SERVICE ADDRESS s '--� 4". /&�v /' q )- "
LOCATION OF DEVICE 9 bo,-k
DEVICE: Wn 9c) 5� gl?
Manufacturer —m-Rel Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2-1p LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
A.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
13
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-1 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
[I
REDUCED PRESSURE
REMARKS:
9-2Q-
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 8,L/T-02-/7
INITIAL TEST PERFORMED BY 'A 11 -4,f OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES f 'n �' / Q
SERVICE ADDRESS
LOCATION OF DEVICE 2- Z)ock'
DEVICE: Wa -ITS - '90ci 170 3
Manufacturer R—odel Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE /0-0 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 9 - .2— LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
)@(
REDUCED PRESSURT
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
6UIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
C1
SEAT -------------
0
LOWER -------------------------
0
R
D IAPHRAGH --------
0
DIAPHRAGM — -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
1MVIA nFAR,
j MR,
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 8q7--
INITIAL TEST PERFORMED BY OF LL cZ DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS ;.- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES J--� L, / 0/--
SERVICE ADDRESS
L u),2
LOCATION OF DEVICE )3cc k /
DEVICE: . 0 Jo, 77--� 90 C)
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 6 -�Z LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT P_ , -/' LBS.
TEST
2. CLOSED TIGHT
fid
2. CLOSED TIGHT
g.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
* 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
'CLOSED TIGHT -----
0
REDUCED PRESSU
� 5 0. "af, AW, ME:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE-.,?..,,. 7-- 2 �
0
INITIAL TEST PERFORMED BY O'�j - ol DATES-// 1`2
REPAIRED BY
DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES Po �- I ol— E
SERVICE ADDRESS
LOCATION OF DEVICE ck
DEVICE: WOL= 900
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE '7
_z , e LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT 2-. 2 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
g
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER -----------------------
C]
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE -------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
C1
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
C - c -)
84/7 ) -- 17
11j -If
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Po v 7- q j.::" Ed
SERVICE ADDRESS 33 62 ZZ-QL boas
LOCATION OF DEVICE L a k
DEVICE: Wa_Ts
Manufacturer M6del Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE �o LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2`1 LBS.
TEST
2. CLOSED TIGHT
pd
2. CLOSED TIGHT
A.
. REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE _- 0
UPPER -------------------------
0
LOWER ---------------
cl
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS: Z&=,212 9
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
1
INITIAL TEST PERFORMED BY OF Patf o/
REPAIRED BY DATE
FINAL TEST.PERFORMED BY OF DATE
0
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES 1-In y- / 0 F F,
SERVICE ADDRESS
F-c
LOCATION OF DEVICE Doe_, k
DEVICE: Ujo, 77-� 9 on q&,
Manufacturer —Mo FeT— Size Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE DROP
ACROSS
FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
C3
1. LEAKED
11
1. OPENED AT 2-4p LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
pl.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEkIED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
[I
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C1
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[I
REDUCED PRESSURE
THE ABOVE REPORT IS CERTIFII,�D TO BE TRUE: 6,41T, o)_j�7
INITIAL TEST PERFORMED BY OF o/ 6V414� DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PRE141SES
SERVICE ADDRESS 3 a to Zn�m U jas L'
LOCATION OF DEVICE A/
DEVICE: � 1 22-= __ 2- 7_0 9 1�
14an-ufactureF M6del Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS.FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
af
REDUCED PRESSUVE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
I
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------------
*0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE _-
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
(I
REDUCED PRESSU
pw
THE ABOVE REPORT IS CERTIFI�D TO BE TRUE: 6,,y7-_02,,7
INITIAL TEST PERFORMED BY �, (
OF DATE S-11 -8�
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
I
1/73
CO
0
if2� (-_, �p� �11
vi
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS L
LOCATION OF DEVICE DOC
DEVICE: Wa DocibLt c�r,k w (0 6- 9.ff L
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
W'2.
CLOSED TIGHT
X.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C]
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
A 4
0
REDUCED PRESSU
A
THE ABOVE REPORT IS CERTIFI�,D TO BE TRUE- 0
lo -9�
INITIAL TEST PERFORMED BY OF DATE
f T
REPAIRED BY --DATE--
FINAL TEST PERFORMED BY OF —DATE
1/73
STREET FIL?
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
n Y, 77 n F Z�,,m o v
SERVICE ADDR ESS ALul'pa L
LOCATION OF DEVICE AQL'f111UC4,
DEVICE: r—e 6 0- 0 c /9 7*1/
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE . 6--5— LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2,1 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
P(.
REDUCED PRESSURT
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE -------------
0
GUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT -------- I ------
[]
SEAT --------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
0
*DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:13,oY77,4 o,�17
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
0 STREET FILE 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: 25-0 /J00 5
. . Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
)0.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
Disc -------------
11
Disc ---------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --1-----..- 0
HINGE -PI N --------
0
UPPER -------------------------
0
I
SEAT --------------
[I
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM— -------
11
DIAPHRAGM, SMALL
S
OTHER,,DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: "�RC-Cn,(ZQC-Q
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: &V/7--40)
INITIAL TEST PERFORMED BY /� ' Z
OF jL-1,T DATE /0 - Ze
REPAIRED BY 7 DATE
FINAL TEST PERFORMED BY OF DATE
il
1/73
STREET FILLO
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES IDov,-T- o F 1--dmoAj�4g
SERVICE ADDRESS
LOCATION OF DEVICE DOC 7
DEVICE: WaM
Manufacturer Of)
Model Size Serial No.
LINE PRESSURE AT TIME OF TEST .
LBS.
PRESSURE DROP ACROSS' FIRST CHECK VALVE LBS.
. CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
13
1. OPENED AT �2_, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
El
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER --------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM— -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
.0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: Re"COR/DC-Eno 94 &_/ug Z!9—.
THE ABOVE REPORT IS CERTIFI TO BE TRUE:
INITIAL TEST PERFORMED BY 11V .- OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
STREET FILO
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES pn Y, F 401A4,0_,Jj
SERVICE ADDRESS eo 24y�o I'V'a L Y-)o,,l
LOCATION OF DEVICE bo c k
DEVICE: 0 //Izaff 9
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
C3
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT ---------------
11
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: R&c6Rn&n //-
THEABOVE.REPORT IS CERTIFIR TO BE TRUE: &17--an-17
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREET FILE 0
.CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES PC3,r'7-
SERVI CE ADDRESS
I I r
LOCATION OF DEVICE
DEVICE: 9100
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 24 LBS.
TEST
2. CLOSED TIGHT
0
CLOSED TIGHT
a
REDUCED PRESSUR E
.2.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
-E
GUIDE ------------
D
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --- r ----
0
DIAPHRAGM -a -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT ------
0
REDUCED PRESSU
6-9-1
REMARKS: X&,Qj?Q60
1/1 A m
FA
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
a
1/73
STREET FILE,
CITY.OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES )OCY)� 0 fg/ AA a A)
SERVICE ADDRESS /'you/
LOCATION OF DEVICE D o c- k'
DEVICE: c� _//2 /,7 0 g
nufacturer Model Size Serial No.
LINE PRESSURE AT T.IME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPEN . ED AT 311
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
_LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------ I ------- 0
DISC -------------
0
DISC.UPPER -------------- --------
cl
R
SPRING -------------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
rUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-; -------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE.--
11
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL:'.
OPENED AT LBS.
TEST
CLOSED TIGHT ------
C1
CLOSED TIGHT ------
11
REDUCED PRESSU
REMARKS:— &-cog-p-e-in IV_
THE ABOVE REPORT IS CERTIFIjp TO BE. TRUE:
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREET FILre
CITY OF EDMONDS --.PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE beic k
_77_�-
DEVICE: pL
. Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
a
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
I
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM
0
DIAPHRAGM - -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: Rr_�r.n a nc=-0 10
THE ABOVE R EPORT IS CERTIFI�P TO BE TRUE: 7- o) /'7 n
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
11
1/73
STREET FILE 9
CITY OF EDMONDS -- PUBLIC WORKS DEPA RTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES pn
SERVICE ADDRESS
LOCAT ION OF DEVICE 1)-o c-
DEVICE: \AJct-M' 900 70 2-2-
Manufacturer el Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
l.. LEAKED
11
1. LEAKED
0
1. OPENED AT 2,91 LBS.
TEST
2. CLOSED TIGHT
P4
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
11
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE, ------------
0
SPRING ---------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER --------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM - -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: c OR foxn- C)
THE ABOVE REPORT IS CERTIFIr 0,)-/ �7
C'V TRUE:
INITIAL TEST PERFORMED BY AA&� 0 F
z4' DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
STREET. F?E
CITY OF EDMONDS -- PLTBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES rh Y- 1 0) r t7dim 0 -v d, �
SERVICE ADDRESS ZXO& , v',a Z /1),x
LOCATION OF DEVICE a0c
DEVICE: 1,k)n -/-TF 91!9 C) V-
Manufacturer Model Size Serial No.
LINE PRESSURE
AT TIME
OF TEST
LBS.
PRESSURE DROP
ACROSS
F.IRST CHECK VALVE
./0 0 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT LBS.
TEST
2. CLOSED T IGHT
OL
2. CLOSED TIGHT
19
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT ------------- �
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
nC_n L//-/
REMARKS:
THE ABOVE REPORT IS CERTIFIPEdO BE 'TRUE:
I
INITIAL TEST PERFORMED BY do OF _DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
CITY OF EDMONDS
ST REET
PUBLIC WORKS
WE
DEPARTMENT
BACKFLOW
DEVICE TEST REPORT
NAME OF PRE141SES Pov-7- oF Ej�mouJ_s
SERVICE ADDRESS
LOCATION OF DEVICE
'Fir
DEVICE: ?n0_ (9, 21, 7 0 ly
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 91, L LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2,1/ LBS.
TEST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
;<.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
D
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
H.INGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C1
OTHER, DESCRIBE _-0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: 7�CCoR jX_-,Q ff
THE ABOVE REPORT IS CERTIFI TO BE TRUE:
INITIAL TEST PERFORMED BY h , OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
10 STREET FILE ie
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TE�T REPORT
NAME OF PREMISES
SERVICE ADDRESS
�LOCATION OF DEVICE 1Z n"-
DEVICE: U)n 7T4 10& 9119
Manufacturer Model Size Serial No. '
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE . .9'o LBS.
- —
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
1. LEAKED
EJ
1. OPENED AT )- , � LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X.
REDUCED PRESSURE
2 DID NOT OPEN
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
11
DISC.UPPER ----------------------
C3
R
SPRING -----------
El
SPRING -----------
El
DISC.LOWER ----------------------
ED
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
1:1
P
PIN RETAINER -----
0
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE -PIN --------
11
UPPER -------------------------
El
I
SEAT --------------
11
SEAT -------------
El
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM -; -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --11
UPPER -------------------------
0
LOWER ---------------
cl
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
I
C1
CLOSED TIGHT -----
-
0
REDUCED PRESSURE
REMARKS:--R(—'c'nRcx0 -
THE ABOVE REPORT IS CERTIFIED TO * BE TRUE: /3//F--g02/7
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
0 ' STREET FILP
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE k'
DEVICE:
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECKVALVE 11 . a LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2.- BS.
TEST
2. C . LOSED TIGHT
go
0'2. CLOSED TIGHT
@0
' REDUCED PRESARTEL
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ------------- ----------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
11
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: !pc=cn_ (:Zoc -14 -8-S ZF
THE ABOVE REPORT IS CERTIFI�D TO BE TRUE: 6Ar-'10_)j7
INITIAL TEST PERFORMED BY OF DATE 9-/
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
11
1/73
STREET FA
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TE.ST REPORT
NAME OF PREMISES _2 7 Edlmll_tAd'�
SERVICE ADDRESS
t f
LOCATION OF DEVICE Do C_
DEVICE: WaTF� 2
Manufacturer AModeP2) Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSUREDROP ACROSS FIRST CHECK VALVE 0 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
o
1 . OPENED AT 2 - J� LBS.
TES T
2. CLOSED TIGHT
(NO012.
CLOSED TIGHT
goo'
REDUCED PRESSURE
I
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
Cl
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT ------
0
REDUCED PRESSURE
104 *IX
THE ABOVE REPORT IS CERTIFIW TO BE T�,UE: 8#7--*op_
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREETOILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES PorT nF
SERVICE ADDRESS
LOCATION OF DEVICE k1 k1
DEVICE.
�2
Manufacturer Model Size Serial-flo.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE s LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT 2.# f LBS.
TEST
2. CLOSED TIGHT
eol.
CLOSED TIGHT
001e REDUCED PRESSUR"I
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
C]
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER ----------------- --------
0
I
SEAT -------------- :
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-1 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
A
0
REDUCED PRESSUIFE
-'EMARKS:'Qr-,r^ 'RQ(�--Q IL Ajf'-�'%
A j - 88 -- .1
THE ABOVE REPORT IS CERTIFIkO TO BE TRUE:13,1/7-'01/�7
INITIAL TEST PERFORMED BY 0 F DATE
REPAIRED BY DATE
FINAL TEST PERFORMED.BY OF DATE
11
1/73
STREEJOFILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Pcor 7
SERVICE ADDRESS 3� /0 I�Z4A4 j vrG WC
LOCATION OF DEVICE
DEVICE: WOL=
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME.OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
K
2. CLOSED TIGHT
REDUCED PRESSURE.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING -------- ------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT --------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-1 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER -----------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT-m.---
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
� M 1 MA MIMI WF-411
THE ABOVE REPORT IS CERTIFIYD TO BE RUE-,6)vr&,m,7
INITIAL TEST PERFORMED BY DATE
0 F
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
STREET FIL4
NAME OF PREMISES
SERVICE ADDRESS
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
Pov,7- ojF Fdlwoxl�.�
-*),n I /-/I , I ''I I
LOCATION OF DEVICE Doc, V
DEVICE: )n:-Tr� I
oy-� w eL-
Manufacturer ffo—d e 1 Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE.DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
1900'2.
CLOSED TIGHT
1#0'
REDUCED PRESSURIE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING ------------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, -LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM - -------
c]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS: cc"O(Zoe�o I � - t
THE ABOVE REPORT IS CERTIFIE 0 'TRUE: &Y�- A'01/7
INITIAL TEST PERFORMED BY A F
DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREET FILD
�v CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
a
SERVICE ADDRESS
LOCATION OF DEVICE A/ D"- L
DEVICE: . I I)a 7rc 900
Manufacturer Model
70
Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 617 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
13
1. OPENED AT LBS.
TEST
CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRES;fREi
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER -------------------------
0
1
1 SEAT ------------- �—'
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --; ------
0
DIAPHRAGM —4 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT---..;—
CLOSED TIGHT -----
0
REDUCED PRESSU
'p
REMARKS: (-- C-ORQCD 11-14:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL -TEST PERFORMED BY
OF jjo�— DATE
REPAIRED'B� DATE
.FINAL TEST PERFORMED BY F DATE
a
1/73
STREET
FlAb
CITY OF EDMONDS
—PUBLIC WORKS
DEPARTMENT
BACKFLOW DEVICE TEST REPORT
IE OF PREMISES UmIaLl
VICE ADDRESS V1 I RA L_
ATION OF DEVICE R 0 F- 3) RJ V I-=. TD GO A-T- Wa-p
rAG_
ICE: (--pne C-0 1q_0 sl— ri (ss) A 61-
Manufacturer Model Size Serial No.
iE PRESSURE AT TIME OF TEST LBS.
SSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
'\DIFFERENTIAL PRESSURE RELIEF VALVE
TIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
2. CLOSED TIGHT
;!S,
2. CLOSED TIGHT
REDUCED PRESSURE
\DI
2. I NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
IN
REPLACED:
REPLACED:
REPLACED:
__D I SC' --'0
DISC
0
DISC.UPPER -- ---------
0
R
SPRING -------- :---
0
SPRING -----------
0
DISC.LOWER ---- ------ -----------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------- -- -------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0.
DIAPHRAGM, LARGE
11
A
HI'NGE PIN --------
0
HINGE PIN --------
0
UPPER -------- -- -------------
L J,
I
SEAT --------------
n
SEAT -------------
El
LOWE� ------- ----- -----------
R
DIAPHRAGM, ---------
[I
DIAPHRAGM— -------
El
DIAPHRAGM, S LL
S
OTHER, DESCRIBE
C3
OTHER, DESCRIBE
UPPER --- ------------ --------
0
LOWER - -------------
13
SPACER OWER
OTHE DESCRIBE
,
NAL
ENED AT LBS.
:ST
CLOSED TIGHT-----
0
CLOSED TIGHT -----
0
Z
REDUCED PRESSUVE
�;ARKS:
ABOVE REPORT IS CERTIFIED TO BE TRUE:
JIAL TEST PERFORMED B 3 OF C(7Y -Or- ADMAMS DATE
V FED BY —DATE
TEST PERFORMED BY OF —DATE
I
10
I
NAME OF PREMISES
ISERVICE ADDRESS
LOCATION OF DEVICE
STREET F10
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
v
DEVICE: Fe -
Manufacturer ffo—del
LINE PRESSURE AT TIME OF TEST
'�., o L
If
LBS.
I . 1
2-- 7�7
Size -�-erial No.
.PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
13
1. LEAKED
.0
1. OPENED AT LBS.
TEST
.2. CLOS . ED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
C L EfhN-E D
11
CLEANED
0
REPLACED:
RETLACED:
REPLACED:
DISC ------------- 0
-;"D I SC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ------- : ---------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING ------- --------------------
.0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, -LARGE
-
A
HINGE PIN ------ �-
0
HINGE -PIN --------
0
UPPER --------------------------
0
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER,,DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
0
REDUCED PRESSU F
REMARKS:
THE' ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY �' Ile OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREEl' FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPART+1ENT
BACKFLOW DEVICE TEST REPORT
1AME OF PREMISES
3ERVICE ADDRESS
-OCATION OF DEVICE Dock
)EVICE:
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
?RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIF FERENTIAL.PRESSURE.RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. �CLOSED TIGHT
REDUCED PRESSURIE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISCAPPER ----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
11
QIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, -LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0.
UPPER -------------------------
0
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM — -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE ---0
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[I
REDUCED PRESSUR—E
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: /gaT oiI7
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73.
STREET FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
INAME OF PREMISES
ISERVICE ADDRESS
d
LOCATION OF DEVICE IDOC
DEVICE: 092-
9
Manufacturer MoTe-l"— Size SeriaT No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 3, 4o LBS.
TEST
2. CLOSED TIGHT
J4
2. CLOSED TIGHT
REDUCED PRESSURIE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 13
DISC -------------
11
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ;' --------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING ---------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER --------------------------
0
I
SEAT -------------
: 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE -- 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: i8jDT CZ)7
INITIAL TEST PERFORMED BY 0 F n E
DAT
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF
1/73
'STREET FILE 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TIEST REPORT
NAME OF PREMISES A YT - a F r-cla-pi e7 -v J s
ISERVICE ADDRESS
LOCATION OF DEVICE (j,
DEVICE: 900 0 -�/ no cl
Manufacturer Mo el Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
1. LEAKED
0
1. LEAKED
0
INITIAL
1. OPENED AT /, t LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
�<
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC --------------
0
DISC..UPPER ----------------------
cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ; --------------
El
E
GUIDE ------------
13
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER --------------------------
0
I
SEAT --------------
D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM - -------
c]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER-, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 60T 02-17
INITIAL TEST PERFORMED BY PS, 1j1ya4Z,_ OF JL,� �Z DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF -DATE
0
1/73
INAME OF PREMISES
ISERVICE ADDRESS
STREET FIL
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
YT n i=
r]
0
LOCATION OF DEVICE Do C- k",
DEVICE: 900 0 J/5- -7 0 9
Manufacturer Model Size �erial No.
ILINE PRESSURE AT TIME OF TEST
IPRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 117 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURT
)<
2. DID NOT OPEN
0
CLEANED
0
CLEANED
C3
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER -------- --------------
0
E
GUIDE ------------
D
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER --, ------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -4 -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C1
OTHER, DESCRIBE -- 0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY /Z OF I o
71 DATE
,7
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
I NAME OF PREMISES
STREET FILO
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
Y,
�SERVICE ADDRESS 334.7 L
LOCATION OF DEVICE, F
DEVICE: pjq]7� 0 J4 1709 2-
F4anufacturer Fo—del Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS..
— —
— CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
13
1. OPENED AT 3,,5 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
fi�
REDUCED PRESSUVE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ; --------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER ------------------------
0
1
SEAT --------------
C1
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
� REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY P OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
u
1/73
�NAME OF PREMISES
SERVICE ADDRESS
-STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
V�T
LOCATION OF DEVICE J0 cc k'
DEVICE:
Manufacturer Model Size Serial No.
ILINE PRESSURE AT TIME OF TEST
LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
1:1
1. OPENED AT 5,2— LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURIE
2 DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
cl
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
11
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- --------------
El
E
GUIDE ------------
13
rUIDE ------------
0
SPRING ---------------------------
0
P
PIN RETAINER ----- 0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER ---------- I ----------------
0
1
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM -------
11
DIAPHRAGM -4 -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE 11
UPPER --- * ----------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: ov7
INITIAL TEST PERFORMED BY OF DATE.
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
'STREET FILE 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE:
F4anufacturer Model Size Serial No.
�LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
— —
— CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT / J1 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURIE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
R�PLACEIQ:
DISC ------------- 0
DISC --------------
0
DISC. UPPER ---------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE -------------
0
SPRING - ------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER ---------------------------
0
1
SEAT -------------
* 0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, -DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 7-
INITIAC TEST PERFORMED BY a OF
4 DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE_
1/73
STREET FILEO
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES AnT -n F Fdmoxl
SERVICE ADDRESS 3,1(0 /7—/C/,'Iq I �- 0 L We
LOCATION OF DEVICE 1<1 6f
DEVICE: 900 2 �70 � 3
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1.
LEAKED
0
1. OPENED AT 3-0
TEST
2. CLOSED TIGHT
>(
2.
CLOSED TIGHT
X
—LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE -------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER --------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-1 -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE -- 0
UPPER ----------------- I -------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
�REMARKS:
THE ABOVE REPORT IS CERTIFIED 0, TRUE: 60T- 0 117 1) 1.
INITIAL TEST PERFORMED BY Apot I -VA 0 F -DATE_R'-5-,ffZ
REPAIRED BY a DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
'STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES —FJo v-,T co F
SERVICE ADDRESS, 33tn //c('1w I'Oa L t04-4
LOCATION OF DEVICE i)c c
DEVICE: 171 777� 9,!�o 0 41-2 2r --Z
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
— —
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
1. LEAKED
0
1. OPENED AT— /- & LBS.
TEST
2. CLOSED TIGHT
pq
2. CLOSED TIGHT
Pk
REDUCED PRESSURE
2.
DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
C]
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ; --------------
0
E
GUIDE ------------
D
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIP --------
0
UPPER --------------------------
0
1
SEAT -------------
: D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-4 -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT-----
0
CLOSED TIGHT -----
D
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIF;ILI TO,2 TRUE: 73DF-02-17 -5-d7
INITIAL TEST PERFORMED BY ZA OF Poj 0� W,—DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
0 - STREET FILFO
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
�-s
SERVICE ADDRESS
I V' Cc L
LOCATION OF DEVICE Poc Ic'
DEVICE: Wa 7 r-s' �00
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT- /; 1171 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 13
DISC -------------
0
DISC.UPPER ----------------------
C]
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ; --------------
0
E
GUIDE ------------
13
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER --------------------------
El
I
SEAT -------------
: 0
SEAT ---- 7 --------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM - -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE -- 0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.-
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: L)7-- 02-/7
6/&Lao� DAT
INITIAL TEST PERFORMED BY OF Dg�j E
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
a
1/73
NAME OF PREMISES
SERVICE ADDRESS
0 STREET FILEO
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
p F Js
0 V_T 0 'Fdvw0'U
33(v A/dm'i v,,n L /1).a u
LOCATION OF DEVICE - - DO C
DEVICE: 900
Manufacturer Model �ize Serial No.
�LINE PRESSURE AT TIME OF TEST
LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE . LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSUR
2. DID NOT OPEN
0
CLEANED
0
CLEANED
1
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER --------- --------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER --------------------------
0
I
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
[]
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 11
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO B TRU : 60T-o2.P7
DATE 9-
INITIAL TEST PERFORMED BY 0 F 0,/
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
vlok:'
INAME OF PREMISES
ISERVICE ADDRESS
STREET
FILE
0
CITY OF EDMONDS -- PUBLIC
WORKS
DEPARTMENT
. BACKFLOW DEVICE TEST REPORT
F Fdmo,-o�
LOCATION OF DEVICE Do a k'
DEVICE: Waars
Manufacturer MoM Size Serial No.
�LINE PRESSURE AT TIME OF TEST
LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
I.. LEAKED
0
1. LEAKED
0
INITIAL
1. OPENED AT �, Z LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
#,
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ; --------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P.
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PI N --------
0
UPPER ----------------------
0
1
. SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE 0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
CI
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT'IS CERTIFIED TO TRUE:- 8,07--01/7
D.
.INITIAL TEST PERFORMED BY D 0 F DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF -DATE
0
1/73
STREET FILE 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE T.EST REPORT
NAME OF PREMISES p
"r PjAjn_iJAs
SERVICE ADDRESS '17-IdAA I.A, I I/)" "
LOCATION OF DEVICE gct g no C_
DEVICE: Wa 1� 900 0
Manufacturer Model �ize Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
1. LEAKED
0
1. OPENED AT 11.3 LBS.
TEST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
A
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ---------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER -------- ; --------------
0
E
GUIDE ------------
D
AUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER --------------------------
0
I
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE 0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
I
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: I t3bT_0)_/7
INITIAL TEST PERFORMED BY OF /) J_
DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
NAME OF PREMISES
'SERVICE ADDRESS
STREET FILE
CITY OF EDMONDS ---P-UBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
0.
LOCATION OF DEVICE A/
DEVICE: / i )cf
Manufacturer Model Size Serial No.
LINE.PRESSURE AT TIME OF TEST LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
— —
— CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT /19 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
)<
REDUCED PRESSUR—E
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER -------- ---------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER --, -----------------------
0
1
SEAT -------------
: D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPE NED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: SDT '0217
INITIAL TEST PERFORMED BY 4" 1 OF DATE 9
REPAIRED BY 0 DATE
FINAL TEST PERFORMED BY OF DATE
a
1/73
STREET FILE*
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
I
SERVICE ADDRESS
R/
!LOCATION OF DEVICE �41
DEVICE: 0 #2�7 0&
Manufacturer Model Size Serial No.
�LINE PRESSURE AT TIME OF TEST
LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
— —
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3 1-/ LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSU
-
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------- ------
D
DISC -------------
11
DISC.UPPER ------------ ----------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER --, -----------------------
0
I
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED 0 BE: T UE: 10 OT- 02/7
Aw
INITIAL TEST PERFORMED BY OF fiv DATE g
i -7-61 - - .
�REPAIRED BY DATE
I FINAL TEST PERFORMED BY OF DATE
a
1/73
.-0 r-, -t �
3L
0 STREET FIGE
."AME OF PREMISES
C ITY OF E DIMONDS - - P UP, i- I C WORKS DE P A RTMENT
B A C-'K F L 0 W D E V I Cr. IEST REPORT
SERVICE ADDRESS
LOCATION' OF DEVICE
_4e
/ ly
DEVICE: 4;-p A , . 14)- 0 d L57�Z
Ma MU t a C W rer Mode I Size Serial Nlo.
L.INE PRESSURE AT TIME OF TEST LBS.
ILI
PRESSURE DROP ACROSS FIRST CIILCK VALVE LBS.
CHECK VALVE iNO. I CHECK VAL"I' NO. 2
INITIAL 1 LEAKED I . LEAKED 0
TEST
2. CLOSED TIGHT L CLOSED TIMIT
R
E
P
A
s
CLEA�.----In
0 1 CLEANED
REPLACED:
DISC -------------
0
SPRING -----------
C1
CUIDE ------------
0
PIN' RETAINER
0
111 E P I t 1- --------
0
SEAT -------- -----
0,
DIAPHRAG:1 --------
0
OTHER, DESCRIBE --
0
FINAL
TEST CLOSED TIGHT ----- 0
11
REPLACED:
DISC ------------- 0
s P p I f " (-�i ---------- 0
(',U 1 OF ------------- 0
P1,11 RETAIiNER ----- 0
141N.".1E PIN -------- 0
SEAT ------------- 0
DIAPHRAGiH -------- 0
OTHER,. DESCRIBE --0
DIFFERENTIAL PRESSURE RELIEF VALVE
1. OPENED AT LBS.
REDUC[D PRESSURE
DID '40T OPEN 0
CLEANED 0
REPLACED:
D I SC. UPPER ----------------------
PI S C. L Cj'-.'ER ----------------------
SPR I NG --------------------------
c-
DIAPHRAGit-I., LARGE
UPI) 17 D - - - - - - - - - - - - - - - - - - - - - - - -- -
C',
L0 - - - - - - - - - - - - - - - - - - - - - - - - -
DIAPI!').AG,'-I, SMALL
UPPER -------------------------
0
LO'-!!:,R ---------------
ci
SPACER, LO',-!FR
OTHER, DESCRIBE
OPEINED AT LBS.
CLOSED TIGHT ---- � 0 1 R E 0 U C -C -6 —MRICS —SU t IT
REMAPKS: tl�,C.o F-'oje &AA17?-X_57
THE ABOVE REPORT IS CERTIFIED TO BEfUE
INITIAL TEST PERFORIIED BY OF D A T C17ZL:r-�:ore
REPAIRED BY DATE
FINAL TEST PERFOMMED BY OF DATE
CE=-LC=Z,
0010
1 /7.1
ie -
STREET
FILE
6
CITY OF EDMONDS
-- PUBLIC WORKS DEPARTMENT
BACKFLOWDEVICE TEST REPORT
NAME OF PREMISES
ISERVICE ADDRESS
�LOCATION OF DEVICE Is Gs b a k "' #I
DEVICE: WGX3 %0 / at
1 nufacturer ffo-del Size Serial -No.
'LINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
- —
— CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2 q LBS.
TEST
2. CLOSED TIGHT
Ero'2.
CLOSED TIGHT
5e'
REDUCED PRESSURE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
13
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
C3
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
C1
I
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
C3
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
11
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFkID TO BE TRUE: (3 DT 0 2J7
.4 mtj4 DATE
INITIAL TEST PERFORMED BY T IJA 0 F '0` 4 `/
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
'NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
0 - STREET FILE*
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
0
0
DEVICE: F -p
e6c
nufacturer Model
1g,
Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
— —
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
WO'2.
CLOSED TIGHT
w
01 REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C3
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT --------------
D
SEAT -------------
0
LOWER -------------------------
13
R
DIAPHRAGM --------
11
DIAPHRAGM— -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
11
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C3
CLOSED TIGHT -----
0
REDUCED PRESSUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: (315row
INITIAL TEST PERFORMED BY ZJA OF 10-A —DATE
01�
�REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
<- ';� i
INAME OF PREMISES
�SERVICE ADDRESS
10 ' STREET FILE*
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
aw"r aF PclmeaJ s
LOCATION OF DEVICE Af Poe k
DEVICE: " m
Manufacturer Model
LINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
/to 04/2-2!10jr/
Size Serial No.
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
IW'2.
CLOSED TIGHT
He
01 REDUCED PRESSURE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
13
SEAT -------------
0
LOWER -------------------------
11
R
DIAPHRAGM --------
11
DIAPHRAGM - -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C3
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: WrO,217
ADO- 11.6 10610' 1110e DATE s7yi 4— r &
IOWA-4"
INITIAL TEST PERFORMED BY OF
REPAIRED BY 0 DATE
FINAL TEST PERFORMED BY OF DATE
1/73
0�_
1p, 1 0 STREET AE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE Do r- k
DEVICE:
ManufaCturer Mddel Size Serial No.
LINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
— —
— CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3- y LBS.
TEST
2. CLOSED TIGHT
90'2.
CLOSED TIGHT
REDUCED PRESSUR
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
11
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
El
P
PIN RETAINER -----
0
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
11
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
cl
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
�REMARKS:
THE ABOVE REPORT IS CERTIFILD TO BE TRUE: 8D7- 011'7
C 1,104% ^& .21.
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF PATE-
1/73
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
�SERVICE ADDRESS .3 3 lo
"wo
'LOCATION OF DEVICE &r- ie
�DEVICE: WOE
I Manufacturer ModeT Size -S -e-r —ia-l- - T1 —o.
ILINE PRESSURE AT TIME OF TEST LBS.
IPRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT LBS.
TEST
2. CLOSED TIGHT
000'2.
CLOSED TIGHT
W
.
.3.5-
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
D
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM -; -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
I
0
CLOSED TIGHT -----
I
0
REDUCED PRESSURE
�REMARKS:
THE ABOVE REPORT IS CERTIFI D TO BE TRUE. 1307 O.V7
INITIAL TEST PERFORMED BY IJ&,n A00% - OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
re
0 * STREET FfE
'IF ,
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
!!NAME OF PREMISES
'SERVICE ADDRESS
LOCATION OF DEVICE 16c k
,DEVICE: 9400 0 JW M_
I wam:
Flanufacturer Model Size Serial No.
�LINE PRESSURE AT TIME OF TEST
�PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT LBS.
TEST
2. CLOSED TIGHT
200'2.
CLOSED TIGHT
w
01 REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
C3
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
C1
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
'REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 80T- 02j-1
r p0jj
INITIAL TEST PERFORMED BY -S OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
0 S T R E. r--- T F I W
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
0
'SERVICE ADDRESS
LOCATION OF DEVICE bar- k
iDEVICE: Trs tv 0 9Z
i
i nufacturer Model Size Serial No.
ILINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
W'2..
CLOSED TIGHT
W
' REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
C3
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
C3
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
11
rUIDE ------------
0
SPRING --------------------------
El
p
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
I
SEAT --------------
11
SEAT -------------
11
LOWER ----- * --------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
IREMARKS:
THE ABOVE REPORT IS CERTIFhID TO BE TRUE:80rottv �ej
6
K /L
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE-
1/73
STREET Fit
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
INAME OF PREMISES
ISERVICE ADDRESS
LOCATION OF DEVICE bar- )e
!DEVICE: JA ). 7rs aj(176irl-
I Mabufacturer Mddel- Size Serial No.
ILINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
— —
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
Ro'2.
CLOSED TIGHf
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
C3
DISC.UPPER ----------------------
C3
R
SPRING -----------
C3
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE -PI N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM -; -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
11
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
[3
REDUCED PRESSU
IREMARKS:
,THE ABOVE REPORT IS CERTIFIE TO BE TRUE:
C. ov-7 - A 0#
INITIAL TEST PERFORMED BY OF DATE
I,. -
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
a
1/78
STREET FIIE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
i
�NAME OF PREMISES P
altr OF AF_dffiQA14,S-
SERVICE ADDRESS hrn(.m i y-a L ujol. 4/
G Dot. k
'iLOCATION OF DEVICE
DEVICE: 900
Flan-ufacturer Size Serial No.
�LINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
L.BS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
Q
1. OPENED AT 3.5- LBS.
TEST
2. CLOSED TIGHT
poo'2.
CLOSED TIGHT
w
REDUCED PRESSUR
0
.
2. DID NOT OPEN
CLEANED
0
CLEANED
D
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C]
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ----------- 1
0
SPRING --------------------------
0
P
PIN RETAINER -----
E3
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
13
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
13
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
C1
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
[I
REDUCED PRESSURE
�REMARKS:
THE ABOVE REPORT IS CERTIFIJD TO BE TRUE- n I
INITIAL TEST PERFORMED BY 19- t /1 A. OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
v
1/73
0
0
STRELFFOILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
ISERVICE ADDRESS
1
�LOCATION OF DEVICE
Dot
IDEVICE:
&&M
Manufactur6r Fod�el '�ize Serial No.
,LINE PRESSURE AT TIME OF TEST
IPRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
- -
- CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
Moe2.
CLOSED TIGHT
le
-14-
r_1 REDUCED PRESSURIE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
El
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
El
I
SEAT -------------
* 11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -; -------
[3
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: Or owy
INITIAL TEST PERFORMED BY )?*So anake I OF DATE
f u
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF
1/73
0 STREET FOE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
INAME OF PREMISES
�SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: 0 1/2*703
Manufacturer Model Size Serial No.
�LINE PRESSURE AT TIME OF TEST
�PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT .26&0 LBS.
TEST
2. CLOSED TIGHT
WO
002' CLOSED TIGHT
1w
- REDUCED PRESSURE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
C1
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE-PI.N --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
C1
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C1
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
0
REDUCED PRESSURE
�REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE- DATE
INITIAL TEST PERFORMED BY j?-SJJ,&. 87 0 F
me, I a7
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
1/73
'5T CITY OF EDMONDS PUBLIOUBT A RQ
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
�SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: "m 0
Manufacturer - Model Ti_ze Serial No.
�LINE PRESSURE AT TIME OF TEST
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 9., V LBS.
TEST
2. CLOSED TIGHT
go
00'2. CLOSED TIGHT
90
Of REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
11
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
11
r.UIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
C3
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE-PI.N --------
0
UPPER -------------------------
C1
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
13
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFI D T B-- TRUE: SJDT- OV7
1) 1
INITIAL TEST 'PERFORMED BY OF DATE
azc orc of
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREEI FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
SERVICE ADDRESS A S3310 AWNI 0 "L
LOCATION OF DEVICE
DEVICE: 104&M
Tl-anufattur&- Model Size Serial No.
�'LINE PRESSURE AT TIME OF TEST
LBS.
,PRESSURE DROP ACROSS FIRST CHECK VALVE I LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT /04( LBS.
TEST
2. CLOSED TIGHT
MO
002'. CLOSED TIGHT
go
" REDUCED PRESSUR
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
cl
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
E3
HINGE -PI N --------
0
UPPER -------------------------
C3
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
11
R
DIAPHRAGM --------
11
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED., TRUE: SIDT OIL17 A I a,
INITIAL TEST PERFORMED BY 0 /J. AL A0,#A OF DATE,
c --Mffl i
REPAIRED BY OF -. DATE
FINAL TEST PERFORMED BY OF DATE
1/73
STREPt FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW-DEVICE TEST REPORT
NAME OF PREMISES P—r oF EJAds
SERVICE ADDRESS
00
LOCATION OF DEVICE L Doc le
�DEVICE: Ulm 0 4t2 Zo k1f
Manufacturer Model Size Serial No.
ILINE PRESSURE AT TIME OF TEST LBS.
� PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
1. LEAKED
0
1. OPENED AT /, j LBS.
TEST
2. CLOSED TIGHT
90'2.
CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
11
CLLANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
11
E
GUIDE ------------
11
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
13
HINGE -PIN --------
0
UPPER -------------------------
C3
I
SEAT --------------
0
SEAT --------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM— -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
El
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE.
0217
INITIAL TEST PERFORMED BY S OF DATE
REPAIRED BY DA TE
FINAL TEST PERFORMED BY OF DATE
11
1/73
P§IREET FILE
CITY OF EDMONDS PUBLIC WORKS DI TM ENT
BACKFLOW DEVICE TEST REPORT
,NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE Do c. K
DEVICE: ul=
Manufacturer Model Size Serial -No.
�LINE PRESSURE AT TIME OF TEST
�PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT / J( LBS.
TEST
2. CLOSED TIGHT
90'2.
CLOSED TIGHT
me,
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
13
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
El
P,
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
13
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
[3
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C1
OTHER, DESCRIBE
0
UPPER --------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY 0 2-T7 OF DATE Z—LV—
REPAIRED BY DATE —
FINAL TEST PERFORMED BY OF -DATE'
11
1/73
�NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
0 1 OSTREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
0 . / so
6
DEVICE: "m 9&0--
Manufacturer Model
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
Size Serial No.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT .5 * [( LBS.
TEST
2. CLOSED TIGHT
go'
2. CLOSED TIGHT
pe
REDUCED PRESSUFE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
11
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
11
E
GUIDE ------------
El
GUIDE ------------
C1
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PI N --------
0
UPPER -------------------------
El
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: sor
INITIAL TEST PERFORMED BY /v - & - OV7 OF DATE
�REPAIRED BY 00, DATE
FINAL TEST PERFORMED BY OF DATE-
1/73
DHONDS I C ,-�ORKS Oil R I H E il T
�TREET Fl�.o* RECEIVED
0[ V-I-(*.-I*..--..-E,ST 1985
-�7 PIP, p / , I
'IAHE OF"hEMISES kt� +-A-M.-
--j
/vy /
�ERVICE ADDRESS
L445�A-WilegLW4y 41
LOCATIOt+ OF DEVICE
CA
DEVICE: N f.Ec e 1 1 ze -�e—rial No.
- Mainufacturer
LINE PRESSURE AT TIME OF TEST LBS. IRIF1
PRESSURE -DROP ACROSS FIRST CHECK VALVE LGS.
0
CHECK VALVE 110.
INITIAL 1. LEAKED
TEST 2. CLOSEDTIGHT
R
E
P
A
R
S
CLEANED
C-111-CK VALVE HO. 2
(J 1 . LEAKED Li
2. CLOSED TIGHT
0 CLEANED 0
REPLACED:
Disc -------------
0
S,"R- T 1-jr, -----------
El
0. - ------------
I
F. I
flfll� RE,,rf,,1NER
! 1 1, 1,(-) E 1) A� i --- --------
SEAT -------------
D h'%PHRW;-'i --------
OTHER, DESCRIBE
-- 0
F I NAL
TEST CLOSED T I GHT ----- EJ
REPLACED:
DI sc -------------
0
SPR I W; -----------
r1ti I DF ------------
1111-1 PETAINER -----
111 fir',E 1) 1 N --------
SEAT -------------
1) 1 APIIRA(,tl
OTHER, DESCR I BE --
IJ
DIFF[PIfITIAL PRESSURE RELIEF VALVE
1. OPENED AT LBS.
2. DID HOT OPEN
CLEA-'IED
REPI-PCEP:
D IS C. 11 P [)!-,R ----------------------
c
P I S C. t. E R ----------------------
C
-.I� ---------------------------
DIAMMAGH, LARGE
LIPPI- ' R -------------------------
c
-------------------------
DIAPIWAGM, SHALL
111,I)i:R -------------------------
1-(' , "![ R ---------------
SPA(TIZ, 1.011-1;.P
OTHER , DESCR I BE
01'Et!LD AT LBS.
CLOSED TIGHT ----- 0 REDUCED PRE UffE
(2e)
REMARKS,
THE ABOVE REPORT IS CER TIFIED T T UE:
_y OF DATEA)
INITIAL, -TEST PERFORHED BY —_p)Mvt1,95
.0 -7 DATE
REPAIRE.0 BY
FINAL TEST PERFORHED 13Y
CERTIFICATE #:
OF
DATE
I / 73
STSEET FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
SERVICE ADDRESS 1331P A -In I %r 6L L
LOCATION OF DEVICE A1QLY1Al2C%.,
DEVICE: Fe L cc) 9 If .2 2
Manufacturer Fo—del Size Serial No.
ILINE PRESSURE AT TIME OF TEST LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK. -VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3-/ LBS.
TEST
2. CLOSED TIGHT
0-2.
CLOSED TIGHT
21
. REDUCED PRESSUFE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
C3
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING ----------- : ----------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE.PIN --------
C3
UPPER -------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM -; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 8Z)7-02/7
41 DATE
!INITIAL TEST PERFORMED BY c/L 0 F &Z
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/73
FILE
S1W
CITY OF EDMONDS--- PUBLIC WORKS.DEPARTMENT
BACKFLOW DEVICE -JEST REPORT
NAME OF PREMISES A rT o F f-ckmoucJE
I SERVICE ADDRESS
I
I
LOCATION OF DEVICE. 6;ea _q Do r= k
DEVICE: OL 170 91 0
Manufacturer Model Size Serial No.
� LINE PRESSURE AT TIME OF TEST 1240 " LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
I INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2"1 LBS.
TEST
2. CLOSED TIGHT
[T'2.
CLOSED TIGHT
'gr'
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:-
REPLACED:
DISC ------------- C1
DISC --------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING -.— -------- ;
0
DISC.LOWER ----------------------
E3
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
C3
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER-
7 ----------------------
0
I
SEAT --------------
11
SEAT -------------
11
LOWER I -----------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM — -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C3
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---- * -----------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS: -
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF DATE �7- 6-�- kS—
e UPT 01/7
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1 7 3
STRI,"U
Fill
CITY OF EDMONDS
PUBLIC WORKS
DEPARTMENT
BACKFLOW,DEVICE-TEST REPORT
NAME OF PREMISES
)-On v, 7— o t='
Lc1mQAJJ
SERVICE ADDRESS
219��
va
LOCATION OF DEVICE
acc-_k
DEVICE: U)Q=s
960
0-YI70
Manufacturer
Model -
Size
Serial No.
LINE PRESSURE AT TIME
OF TEST
LBS.
PRESSURE DROP ACROSS
FIRST CHECK VALVE-
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
1:1
l.- OPENED AT .1' � LBS.
TEST
2. CLOSED TIGHT
IZ5,
CLOSED TIGHT
E�-
--" REDUCED PRESSUVE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
D
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 11
DISC ----------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
nUIDE __.� ---------
c]
SPRING --------------------------
C3
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
: 0
SEAT -------------
0
LOWER --' _� ---------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM— -------
c]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ----------------
0
-SPACER, LOWER
OTHER,.DESCRIBE
FIN L
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
�REMARKS:
THE ABOVE REPbRT IS CERTIFIED 'TO BE TRUE:
INITIAL TEST PERFORMED BY
OF DATE
REPAIRED BY 0 /3 DT OZi7 DATE
FINAL TEST PERFORMED BY OF DATE
1/73
NAME OF PREMISES o F Cznt& tiAJa[9
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: Wat
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE,
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2_,3_ LBS..
TEST
2. CLOSED TIGHT
gr'2.
CLOSED TIGHT
0
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
a
DISC -------------
11
DISC.UPPER ----------------------
C3
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------- r ----
0 i
E
GUIDE ------------
El
GUIDE ------------
El
SPRING --------------------------
F1
P
PIN RETAINER -----
13
PIN RETAINER -----
C3
DIAPHRAGM, LARGE
A
HINGE PIN ---------
0
HINGE -PIN --------
0
UPP;R -------------------------
Cl
SEAT --------------
11
SEAT -------
C3
LOWER.-.r -----------------------
El
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --El
UPPER -------------------------
0
LOWER ---------------
SPACER,.LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
-CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY _Af, 1,�A,4ZA OF &fav"� DATE 7-5 -,?r
0 r3 0 T 0 2-17 DATE
REPAIRED BY
FINAL TEST PERFORMED BY OF DATE
1/73
ITRiLL I I LE
CITY OF EDMONDS---' PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
:NAME OF PREMISES
a
�'SERVICE ADDRESS
ILOCATION OF DEVICE (f DOC, 41
DEVICE: 9m -,yl gn 5p
Ranufacturer Model Size Serial No.
LINE PRESSURE AT T 15 IME OF TEST /Z 4p LBS.
�'PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
C3
1. LEAKED
El
1. OPENED AT JoQ LBS.
TEST
2. CLOSE . D TIGHT
2. CLOSED TIGHT
iir
REDUCED PRESSUR
2. DID NOT OPEN
cl
CLEANED
C3
CLEANED
11
CLEkED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER -----------------------
cl
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
rUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
C1
SEAT -------------
0
LOWER _'L -----------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -a ------
E]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C3
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
gt�� 0�� DATE _j - 1?6
INITIAL TEST PERFORMED BY OF
0 _5DT- 0117 Z
",REPAIRED BY DATE
I
FINAL TEST PERFORMED BY OF DATE
ft
.1'. 4.
EET 71! E
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
t.NAME OF PREMISES
1,SERVICE ADDRESS
�LOCATION OF DEVICE ioc C'k
DtVICE: ID& _rL 9JQ 0 Q'vg909j
Manufacturer Model.. Size Serial No.
LINE PRESSURE AT TIME OF TEST 1_2 4o LBS.
1PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK.VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 2-1,5-
TEST
, "
2', CLOSED TIGHT
a
CLOSED TIGHT
0
_LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED'
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- �-11
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING ---------- _*
0
SPRING -, ----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE -" ---------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PI.N --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
11
SEAT -------------
0
LOWER ' ----------------------
11
R
DIAPHRAGM --------
0
DIAPHRAGM-.; -------
c]
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER ------- ------------------
0
LOWER ----------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT
0
REDUCED PRESSU
.REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE.
INITIAL TEST PERFORMED BY 10^,A 1A OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/ 73
L
CITY OF EDMONDS PUBLIC'WORK'S DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1 NAME OF PREMISES
ISERVICE ADDRESS
LOCATION OF DEVICE
At
��DEVICE: 9-00 0 461_'-70g�7
Manufacturer Mod —el Size -Serial No.
LINE PRESSURE AT TIME OF TEST. 12- to LBS.
,PRESSURE DROP ACROSS FIRST CHECK VALVE. LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
11
1. OPENED AT 2-,, 1 LBS.
TEST
2. CLOSED TIGHT
a
e'
2. CLOSED TIGHT
le
1-11 REDUCED PRESSUKE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER -------------------------
0
E
GUIDE ------------
11
GUIDE ---� ---------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
11
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
11
LOWER ----------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C1
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ----- * ----------
0
SPACER, LOWER
OTHER, DESCRIBE
FIN L
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
;:THE ABOVE REPORT IS CERTIFIED TO BE
INITIAL TEST PERFORMED BY OF DATE
d4l
0 S or 2.17
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/ 73
-77:
FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES 0 F
SERVICE ADDRESS L
LOCATION OF DEVICE
tDEVICE:
Wla 0JI17OL-1,
__Te_l �erial No.
Ranufacturer Mo Size
JINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
,CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
Cl
I . LEAKED
0
1. OPENE D AT Z-5- LBS.
TEST
2. CLOSED TIGHT
Gr
'2. CLOSED TIGHT
R'
�__ REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
Cl
DISC -------------
11
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER -----------------
11
E
GUIDE ------------
11
GUIDE -------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE -PIN --------
0
UPPER -7 -----------------------
0
I
SEAT --------------
0
SEAT -------------
11
LOWER -------------------------
11
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
11
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY 0 . 80'r 0117 DATE
FINAL TEST PERFORMED BY OF DATE
Ll
Y,
or
L
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES 7- o F
SERVICE ADDRESS WTI
LOCATION OF DEVICE 61 Doc k
DEVICE: Z, Oa Z/_ Ty 900
Flanufacturer model Size Serial No.
� LINE PRESSURE AT TIME OF TEST / le.0 _LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
l.. OPENED AT 2- 2- LBS.
TEST
2. CLOSED TIGHT
a'2.
CLOSED TIGHT
21-
REDUCED PRESSURE
.
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
cl
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 1:1
DISC -------------
0
DISC.UPPER' ---------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER -----------------
0
E
GUIDE ------------
11
GUIDE -" ---------
0
SPRING ---------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER ----------------------------
0
I
SEAT -------------
: 11
SEAT -------------
0
LOWER _'�: -----------------------
cl
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER ------------------- ------
- 0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
�'REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY
OF DATE 7-5-g's-
REPAIRED BY DATE
OF DATE
JINAL TEST PERFORMED BY
1/78
I-x OTREU FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF -PREMISES A v-7- c F Ad -In C A 101
a
.SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: g�Z) 77? �J
Ranufatturer. Model Size Serial No.
�ILINE PRESSURE AT TIME OF TEST LBS.
1PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 1' 2- LBS.
TEST
2. CLOSED TIGHT
[9,
'-'2 . CLOSED TIGHT
190,
REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED��'.-
13
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING ------------
DISC.LOWER ----------------------
13
E
GUIDE ------------
El
r-UIDE -" ---------
0
SPRING --------------------------
El
P
PIN RETAINER -----
13
PIN RETAINER -----
0
DIAPHRAGM, LARG E
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
: 11
SEAT -------------
0
LOWER _'.: -----------------------
0
R
DIAPHRAGM --------
[I
bIAPHRAGM —
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C3
OTHER,.DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS: AlfuJ ce u, r
THE ABOVE REPORT IS CERTIFIED TO PE TRUE:
INITIAL TEST PERFORMED BY 44" I.A OF P,�� DATE
8 DT— 7
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF —DATE
4
J/ 7 3'
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
I;NAME OF PREMISES - �AvT o Ar L-dmcAjJ r
' SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: WaTrg goo 0 -V1 7
Manufacturer Model Size Serial No.
,LINE PRESSURE AT TIME OF TEST /IZO LBS.
1PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 2-- Lo LBS.
TEST
2. CLOSED TIGHT
62-
CLOSED TIGHT
93`
'� REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEAONED
0
.REPLACED:
REPLACED:
REPLACED:
DISC -------------
D
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
11
GUIDE ---: ---------
0
SPRING --------------------------
El
P
PIN RETAINER -----
13
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -7 -----------------------
0
SEAT -------------
13
SEAT -------------
0
LOWER' ----------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM -4
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
13
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSUVE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY OF DATE �X-f- 9,�;-
REPAIRED BY U . IVOT 021 . 7 DATE
FINAL TEST PERFORMED BY OF DATE
'1/78
4TRETT FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE DOC k
,DEVICE: u)-a m 940 2 3
Ranufactur-er Model Size Serial No. —
!LINE PRESSURE AT TIME OF TEST. LBS.
:PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
C3
1 . LEAKED
0
1. OPENED AT 2-- 3 LBS.
TEST
2. CLOSED TIGHT
i�r
'2 CLOSED TIGHT
B"
REDUCED PRESSUVE
2. DID NOT OPEN
0
CLEANED
0
CLEANED.
C3
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
El
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
0
SPRING ------ * --------------------
El
P
PIN RETAINER -----
0
PIN RETAINER
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
C3
I
SEAT --------------
0
SEAT -------------
0
LOWER _m --------------- Lt -------
E3
R
DIAPHRAGM -------
11
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER ----------------- ------
0
LOWER ---------------
C3
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
E3
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BETRUE:
INITIAL TEST PERFORMED BY Yc4 --,?C
4v,-.) OF DATE "7-,S
U 80T 0117
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/ 73
S T R E LE'
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
I NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE D., k
DEVICE: T a _yu) 0 -�41 7 2-
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST 11L0 LBS.
.PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
ET2.
CLOSED TIGHT
E;K
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED.
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
1:1
DISC -------------
0
DISC.UPPER -----------------------
0
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
11
SEAT -------------
11
LOWER _"� ------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-;
[]
DIAPHRAGM, SMALL .
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
/) IL
INITIAL TEST PERFORMED BY OF DATE
U a 0r 0%17
REPAIRED BY DATE
.FINAL TEST PERFORMED BY OF DATE
ft
1/73
71E
STR=...
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE
DEVICE: Wex 0 *1 offo-
Manufacturer Model Size Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2— * e LBS.
TEST
2. CLOSE . D TIGHT
gr
""2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
-REPLACED:
DISC -------------
C1
DISC -------------
0
DISC.UPPER ------------------------
El
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE -------------
0
SPRING --------------------------
El
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
11
LOWER --------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM— -------
D
DIAPHRAGM, SMALL '
S,
OTHER, DESCRIBE
C1
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY A4,4 OF ,Z DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
1/ 73.
I;NAME OF PREMISES
1,SERVICE ADDRESS
STRET
FILE
CITY OF EDMONDS.., PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
I -A
I
,LOCATION OF DEVICE' C_
.DEVICE: W a7T7s 0#270VO
�erial No.
Manufacturer Model— Size
LINE PRESSURE AT TIME OF TEST. 4140 �LBS.
�PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
El
1 LEAKED
0
1. OPENED AT 2-9' LBS.
TEST
2. CLOSED TIGHT
(X*2.
CLOSED TIGHT
21,
., REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
Cl
DISC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0,
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
11
SEAT -------------
0
LOWER; ------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM— -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE,--
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY y4&4M__j OF DATE
REPAIRED BY 0 . 4? Wr o,2.17 DATE
,FINAL TEST PERFORMED BY OF DATE
13
6
1/73
FILE
tTR' L
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
11
SERVICE ADDRESS
7LOCATION OF DEVICE no c'
DEVICE: tt)12 7-y 900 0 j/Z70913
Manufacturer Model Size Serial No.
� LINE PRESSURE AT TIME OF TEST ' /2- G LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
I INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT 3,,�, LBS.
JEST
2. -CLOSED TIGHT
91
'-2. CLOSED TIGHT
ciloo
REDUCED PRESSURIE
0
2. DID NOT OPEN
CLEANED
C3
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC —------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
C3
I
SEAT --------------
11
SEAT -------------
0
LOWER_� ------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
11
DIAPHRAGM, SMALL �
S
OTHER, DESCRIBE
11
OTHER, DESCRIBE
UPPER ------------------- rot— ----
0
LOWER ----------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: zi
INITIAL TEST PERFORMED BY 1�&Qm OF DATE
7 a 17
REPAIRED BY DATE
FINAL TEST.PERFORMED BY OF DATE
1/73
L
or R -E C.E. I V E.D.
STRE FILE -0-:0
CI TY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
aaQ0 K9.
.-W
, Ak-
BACKFLOW DEVICE TEST REPORT
4AME OF PREMISES
SERVICE ADDRES�
-OCATION OF DEVICE GAS J)oce-
It
)EVICE: Lj A-rj- 0 o4-x7oR6
Manufacturer Size Serial No.i
�-INE PRESSURE AT TIME OF TEST 12 (1 LBS.
�)RESSURE DROP ACROSS FIRST CHECK VALVE —LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
1 . LEAKED
El
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
C1
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC --------------
El
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
UPPER -------------------------
0
1
SEAT -------------
C1
SEAT -------------
El
LOWER -------------------------
13
R
DIAPHRAGM --------
11
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL-
OPENED AT LBS.
TEST
CLOSED TIGHT-----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
T /-" 0 F C t -ty r>ZI�7o mXk-!� DATE 7-7- Rw
INITIAL TEST PERFORMED BY DATE
rIPAIRED BY
NAL TEST PERFORMED BY OF DATE
Is
10
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
,1AME OF PREMISES Pq RT 0 F- & W70 N D 5
_)ERVICE ADDRESS A -I> tl I r,-aL L4 ) A Y
�_OCATION OF DEVICE -Do Cj<
.)EVICE: (IJA-f-rs CM0
Manufacturer Model Size Serial No.
I
PRESSURE AT TIME OF TEST la(l LBS.
I)RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
I NITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT 9�?, 9 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC 77 ---------
0
DISC --------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
C1
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIB E
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED A LBS.
TEST
I
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
TH E ABOVE REPORT IS CERTIFIED TO BE TRUE:
C 9 ?S'3
N IT IAL TEST PERFORMED BYIAP,�44/t� -_ OF C 17- y o r r5Zr70AiP_S -DATE.
1qI PAIRED BY DATE
, NAL TEST PERFORMED BY OF DATE
15
CITY OF'EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
,�AME OF PREMISES PORT- 0('- E3W-70mv_s
:,ERVICE ADDRESS
-OCATION OF DEVICE it 13 -Do cf<-
)EVICE: w A _T_T_ S 900 L
Manufacturer Model Size ferial No.
-INE PRESSURE AT TIME OF TEST LBS.
-TESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
13
1. LEAKED
0
1. OPENED AT 3._L_LBS.
TEST
2. CLOSED TIGHT
-;k
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
E3
CLEANED
C3
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
E3
DISC.UPPER -----------------------
El
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
13
DIAPHRAGM, LARGE
A
HINGE Pjtj --------
0
HINGE PIN --------
E3
UPPER -------------------------
0
1
SEAT -------------
C1
SEAT -------------
13
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- ;
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
11
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
13
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
—PRESSURE
TEST
I
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
-
REDUCED
i
REMARKS:
i
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
IN ITIAL TEST PERFORMED BYIQLca�,� 71?3 OF cf-r-1 6F GDf?ovp_s DATE Z-7 - 8��
PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
CITY OF*EDMONDS PUBLIC WORKS DEPARTMEN"T
BACKFLOW DEVICE TEST REPORT
`�AME OF PREMISES POIRT- or- &1:>r-70r41>s
-)ERVICE ADDRESS P-Dtlf"L WA-/
.-OCATION OF DEVICE C- T>0C4e-
.)EVICE: L---j A -rr 5 C�00 ?L
Mnn"fnrfurer Model Size Serial No.
�-INE PRESSURE AT TIME OF TEST 1 2-C LBS.
'RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
LEAKED
0
1 . OPENED AT -? . 7 LBS.
TEST
2. CLOSED TIGHT
tg�
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
13
CLEANED
C3
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -L ---------
0
SPRING -----------
0
DISC.LOWER -----------------------
0
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
UPPER --------------------
0
I
SEAT -------------
C1
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
D
DIAPHRAGM - -------
[]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --13
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
IN I ITIAL TEST PERFORMED3 cc -s OF Ct7Y OF 6kDa7Q"bS DATE -21-Z7 -,9!gL
PPAIRED BY DATE
INAL TEST PERFORMED BY OF DATE
C . ITY OF'EDMONDS —PUBLIC WORKS DEPARTME9T
BACKFLOW DEVICE TEST REPORT
4AME OF PREMISES P6 oe T- OF EDMOND-S
)_ERVICE ADDRESS
-OCATION OF DEVICE 2)_ 2 �) 0 C_ 1, e-
)EVICE: irs- Q 9 0 a
Manufacturer Model Size S&ial No.
...INE PRESSURE AT TIME OF TEST /2C.' LBS.
i
:1RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
El
1. OPENED AT '�. 4 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REP LACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C3
R
SPRING -----------
0
SPRING ------- 7 ---
0
DISC.LOWER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
0
p
PIN RETAINER -----
11
PIN RETAINER -----
C3
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
C1
SEAT -------------
11
LOWER -------------------------
13
R
DIAPHRAGM --------
D
DIAPHRAGM - -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --,E]
UPPER --------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
IN I ITIAL TEST PERFORMED BYji�/,k,/� 513 OF c f7-y Cc DATE
_bt7
^PAIRED BY DATE
"'rINAL TEST PERFORMED BY OF DATE
L
r-
L
NAME OF PREMISES
.)ERVICE ADDRESS
.-OLATION OF DEVICE
4fil. . 4 6v�;
CITY OF'EDMONDS -- PUBLIC WORKS DEPARTMEtIT
BACKFLOW DEVICE TEST REPORT
006 RT_ 6 r- r-
I
.)EVICE: WATT-5 goo 4:Q:2p R 7
Manufacturer go -del Size Serial No.
..INE PRESSURE AT TIME OF TEST fz(:, LBS.
IRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
IN ITIAL
1. LEAKED
C3
1 LEAKED
1:1
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
K
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
13
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
El
R
SPRING -----------
0
SPRING ------------
13
DISC.LOWER ----------------------
0
E
GUIDE ------------
C3
GUIDE ------------
El
SPRING --------------------------
C1
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
,A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
C3
I
SEAT -------------
El
SEAT -------------
El
LOWER -------------------------
11
R
DIAPHRAGM --------
0
DIAPHRAGM - -------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
El
OTHER, DESCRIBE --
El
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C3
CLOSED TIGHT -----
11
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT -IS CERTIFIED TO BE TRUE:
I ccs
INITIAL TEST PERFORMED BYtq,�CtZ/�
OF cl?�Y or- =Z)p7oAjDs DATE_7-7-52�4
PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
I
CITY OF*EDMONDS —PUBLIC WORKS DEPARTMEWT
BACKFLOW DEVICE TEST REPORT
1AME OF PREMISES PQR7- 0 CZ E
�)ERVICE ADDRESS Q:br7(P_AL LJA'j
-OCATION OF DEVICE :C) 0 Cx,
)EVICE: L't A =s 0 C-) C3 4 ;� -�?(o R
Manufacturer Model Size Serial No.
-INE PRESSURE AT TIME OF TEST 1-Z G LBS.
'RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
EJ
1 . LEAKED
El
1. OPENED AT ? . 7 _ __jLBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED —PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
C3
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER -----------------------
C3
R
SPRING -1 ---------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN ........
0
UPPER -------------------------
C3
I
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --El
UPPER -------------------------
0
LOWER ---------------
13
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT -IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY(!��_4 CICS ;>93 DATE 7-77-a
0 F C-17-Y or 6.Dt-1e)mD_S
PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
I
,�'AYE OF PREMISES DMON D-S.
0 F- E
ERVICE ADDRESS L-,JA'-1
:_OCATION OF DEVICE -D 0(--4<.
:)EVICE: L047-7—s 9 00
Manufacturer Model Size Serial No.
i-INE PRESSURE AT TIME OF TEST LBS.
'.)RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
IN I ITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT _,Z. 5- LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
D:
DISC -------------
0
DISC -------------
C3
-----
DISC.UPPER ----------------------
El
R
SPRING -----------
0
SPRING ----- * ------
0
DISC.LOWER -----------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
HINGE PIN -------- 0
HINGE PIN --------
E3
UPPER --------------------
0
�A
I
SEAT -------------
0
SEAT -------------
0
LOWER -------- ---------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
F INAL
TEST
CLOSED TIGHT -----
11
CLOSED TIGHT -----
11
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
cc S
INIITIAL TEST PERFORMED BYeg6,,��� 0 F Cl* 7*' Y 0 r 0LD 170AIP -3 DATE -7-7
PAIRED BY DATE
INAL TEST PERFORMED BY OF DATE
r-�
LZ
CITY OF'EDMONDS -- PUBLIC WORKS DEPARTME�T
BACKFLOW DEVICE TEST REPORT
IAME OF PREMISES PN�T- Qf-- C--Dr7OP40.3
)ERVICE ADDRESS" Ad) rl ( 10-4 L tdV
-OCATION OF DEVICE DOCK
)EVICE: (-JA -1-r s
Manuf cturer -Mo d el- Size Yeei-61- No.
..INE PRESSURE AT TIME OF TEST 1-;� (cl LBS.
IRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
E3
1. LEAKED
13
1. OPENED AT f�:&�LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
A
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
cl
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
E3
DISC.UPPER -----------------------
0
R
SPRING -----------
13
SPRING ----- I ------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
E3
p
PIN RETAINER -----
El
PIN RETAINER -----
E3
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
11
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -:
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --[3
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS: N � W 2>g�t/l crm. (" s -TA:q� (0 - I C/ 4
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY&�C 7930F C(?.y gic GLDf7aAjp3 DATE 7--7- c94
^PAIRED BY DATE
'4�'INAL TEST PERFORMED BY OF DATE
I
ON
CITY OF*EDMONDS -- PUBLIC WORKS DEPARTMEWT
BACKFLOW DEVICE TEST REPORT
IAME OF PREMISES
-)ERVICE ADDRESS
'-OCATION OF DEVICE D/o C44�
DEVICE: w A 7-T-S
Manufactu'rer Model Size _5e- 0 a-r 'N iY.
.-INE PRESSURE AT TIME OF TEST Q LBS.
�RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
11
1. OPENED AT _?. o-2- LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
C3
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
C1
UPPER -------------------------
0
I
SEAT -------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT ------
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE -
INITIAL TEST PERFORMED -BY OF C'1'7, y (j)c Ab?7.o"-p
DATE_Zg-&.
AWPAIRED BY DATE
'��INAL TEST PERFORMED BY OF DATE
MIRTNI
Ltt
r-
75.
1;2
1AME OF PREMISES
SERVICE ADDRESS
&WITS
C . ITY OF'EDMONDS -- PUBLIC WORKS DEPARTME*'
BACKFLOW DEVICE TEST REPORT
..00ATION OF DEVICE 'Doc4v,
)EVICE: C4 d 0 14 ;� -709 3
Manufacturer Modef __ Size -Serial No.
_INE PRESSURE AT TIME OF TEST / : Z CC LBS.
)RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
C3
1. LEAKED
11
1. OPENED AT C, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
tal
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
El
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
C3
DISC.UPPER -----------------------
C1
R
SPRING ------------
0
SPRING -----------
ED
DISC.LOWER ----------------------
0
E
GUIDE ------------
C3
rUIDE ------------
EJ
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
E3
UPPER ----------------------
I
SEAT -------------
13
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
11
REDUCED PRESSUFE
REMARKS:
THE ABOVE REPORT -IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BtJ�� 7&,30F Ct-rYOP C-?,h17QMQ_S DATE 7
qPAIRED BY DATE
5INAL TEST PERFORMED BY OF DATE
I
CITY OF'EDMONDS -- PUBLIC WORKS DEPARTMEN-T
Ask BACKFLOW DEVICE TEST REPORT
%w,
11
,1AME OF PREMISES
)ERVICE ADDRESS
:-OCATION OF DEVICE Do C4"-
DEVICE: UJATrS P-0
Manufacturer Model Size Serial -No.
�_INE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3 . C) LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
i
REPLACED:
REPLACED:
DISC ------ -------
0
DISC -------------
El
DISC.UPPER ----------------------
El
R
SPRING -----------
11
SPRING -----------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
El
GUIDE ------------
13
SPRING --------------------------
C3
P
PIN RETAINER .....
El
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
C3
UPPER -------------------------
0
I
SEAT -------------
El
SEAT -------------
13
LOWER -------------------------
Ej
R
DIAPHRAGM --------
0
DIAPHRAGM-: -------
13
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --E]
UPPER -------------------------
C3
LOWER ---------------
C3
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
i
CLOSED TIGHT -----
C3
CLOSED TIGHT -----
0
REDUCED PRESSU
REMARKS:
TH E ABOVE REPORT IS CERTIFIED TO BE TRUE:
IN,ITIAL TEST PERFORMED OF C/7--/ c)ic &DI?6M43 DATE
w"rPAIRED BY DATE
"'Mr —
'��I'NAL TEST PERFORMED BY OF DATE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
'JA E OF PREMISES
MI
�ERVICE ADDRESS
-OCATION OF DEVICE I) o ct<
I
)EVICE: 4) T-r 90o O�4 :?_70 Rt;_
Size Serial No.
Manufacturer Model
-INE PRESSURE AT TIME OF TEST fc;?(, LBS.
I
)RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
E3
1. OPIENED AT 3 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
CrD_VRO
REDU ESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER -----------------------
C3
R
SPRING -----------
C3
SPRING -----------
El
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN ........
0
UPPER -------------------------
0
SEAT -------------
C1
SEAT -------------
0
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C1
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
ID
SPACER, LOWER
OTHER, DESCRIBE
F INAL
OPENED AT LBS.
TEST
I
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
I
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
1 003
IN,11JAL TEST PERFORMED BY?jo=,6c� 0 F Cj 7: Y a r P� ?N t-,uAAn_3 DATE-7-7-
PAIRED BY DATE
INAL TEST PERFORMED BY OF DATE
10
CITY OF'EDMONDS —PUBLIC WORKS DEPARTMEWT
BACKFLOW DEVICE TEST REPORT
1AME OF PREMISES ffo 8 7- cr- F_ D�? 0 m 1) -5
SERVICE ADDRESS
�_OCATION OF DEVICE IT) 0 cl<
DEVICE: (1019 I-r_s
ufacturer go -del Size SeriaT No.
;_INE PRESSURE AT TIME OF TEST I.?- C, LBS.
)RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
1:1
1. OPENED AT ? - C, LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
0,
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC - - - 7 ---------
0
DISC -------------
0
DISC.UPPER ----------------------
C3
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
E3
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
C1
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: ccS 2.0j
INITIAL TEST PERFORMED BY OF c/ 7-y o p abJ170AfP,51 -DATE 7--7-E4
PAIRED BY DATE
INAL TEST PERFORMED BY OF DATE
m
5?��
qAME OF PREMISES
CITY OF*EDMONDS —PUBLIC WORKS DEPARTMEWT
BACKFLOW DEVICE TEST REPORT
6 r-
ADDRESS A 1) tn I 0&A- (_ CJA �Z
:-OCATION OF DEVICE N :Do CKI_
OEVICE: k)A T7- S__ ?0C) -70 R.3
Manufacturer Model Size Serial No.
_I�E PRESSURE AT TIME OF TEST LBS.
)R(SSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
13
1. LEAKED
0
13
1. OPENED AT C� LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC --- 7 ---------
0
DISC -------------
C3
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING ------- ---
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
11
SEAT -------------
11
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM — ------
C]
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
REkARKS:
I
THE ABOVE REPORT IS CERTIFIED TO BE TRUE- C-C-S *7 &-3
INITIAL TEST PERFORMED B DATE X7—n
0 F C/ 7- y d r-
MAPKPAIRED BY DATE
%16NAL TEST PERFORMED BY OF DATE
STREET FILE
R9MV0
0
4
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
0 5 1983
\1AME OF PREMISES POPr OF- E—Dr7OWDS
SERVICE ADDRESS 4-6S A3)r7fnAL (-JA*"/
-OCATION OF DEVICE GA3 -DOC'K
)EVICE: LJ A-r-r S C� 0 04--)-70go
Manufacturer Model Size Serial No.
t-INE PRESSURE AT TIME OF TEST LBS.
ORESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALV E NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
El
_?, ') LBS.
1. OPENED AT ,
TEST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
D
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
11
R
SPRING -----------
11
SPRING -----------
0
DISC.LOWER ----------------------
11
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
P
PIN RETAINER -----
El
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
13
UPPER ----------------------
I
SEAT -------------
11
SEAT -------------
El
LOWER -------------------------
El
R
DIAPHRAGM --------
El
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --EJ
UPPER -------------------------
1:1
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL,
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
T
INITIAL TEST PERFORMED BY 0 F c -ry azew m_v� DATE
0 PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
�-N �
4
0 . * STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
OF PREMISES PO RT 0 E &DOO N D -5
)ERVICE ADDRESS G A-D M I kaL j9 Y
:-OCATION OF DEVICE A -Do Cx-
DEVICE: (IJATMS
Manufacturer Model Size Serial No.
.-INE PRESSURE AT TIME OF TEST Q- 6.1 LBS.
:RESSURE DROP ACROSS FIRST CHECK VALVE
m
CHECK VALVE NO.-
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
1 . LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. 1 CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
El
R
SPRING -----------
El
SPRING -----------
El
DISC.LOWER ----------------------
0
E
GUIDE ------------
ED
-iU I DE T -----------
C
I]
SPRING --------------------------
E]
P
PIN RETAINER -----
0
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
C3
UPPER ----------------------
I
SEAT -------------
El
SEAT -------------
El
LOWER -------------------------
13
R
DIAPHRAGM --------
El
DIAPHRAGM --------
11
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
E]
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSUffE-
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
"INITIAL TEST PERFORMED 2 S-3 0 F c f 7- c) r tsZ r70A#,P S DATE '7-
1 PAIRED BY DATE
PIINAL TEST PERFORMED BY OF DATE
STREET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
'4AME OF PREMISES Q�-' EDMUD-S
:)ERVICE ADDRESS 4G�; ApmiieAL_ tLjM__
-OCATION OF DEVICE -Do C(<_
)EVICE: WA-rT-s '�?()C)
Manufacturer Model � Size Serial No.
-INE PRESSURE AT TIME OF TEST 12-6. LBS.
'RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 3. / LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
11
DISC.UPPER ----------------------
El
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
El
SPRING --------------------------
El
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE PIN --------
0
UPPER -------------------------
I
SEAT -------------
11
SEAT -------------
E3
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM - -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C1
OTHER, DESCRIBE --
0
UPPER -------------------------
C3
LOWER ---------------
13
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
11
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BYe�4 OF C(-r-/ dF e�Dfmvp_s DATE 7-
PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
0
',IAME OF PREMISES
4
0 STREET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
poiRr or- &j:>r7ow>S
ADDRESS 4(,!E3' A-Dt11R4L WAY
it to
.-OCATION OF DEVICE C_ _D0C4e_
)EVICE: L-j(-)-r1_—_s CM0 e3 4 a::z o9 2—
Manufacturer Model Size Serial No.
.-INE PRESSURE AT TIME OF TEST 12-(. LBS.
)RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE No.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
F-1
0
I. LEAKED
El
1. OPENED AT-?, 7 LBS.
TEST
REDUCED PRESSURE
2. CLOSED TIGHT
2. CLOSED TIGHT
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
El
DISC.LOWER ----------------------
El
E
GUIDE ------------
El
GUIDE ------------
El
SPRING --------------------------
11
p
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
F-1
UPPER -------------------------
I
SEAT -------------
11
SEAT -------------
El
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
11
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
FINAL
TEST
CLOSED TIGHT -----
11
CLOSED TIGHT -----
El
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED B�� cs OF Cf 7Y OF S0h*vbS DATE 7-A-1 -,9
10 PAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
9
STpEET FILL'
0
4
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
4PIE OF PREMISES P60eT, OF EDMONDS
:IERVICE ADDRESS J) Je4 L UJA
-OCATION OF DEVICE 2) -1) 0C-("-'
IEVICE: (4 ) A U--s. C70 0 04 290 a/
Manufacturer Model Size SeMdl-No.
...INE PRESSURE AT TIME OF TEST 12-r. LBS.
.1RESSURE D ROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
El
1. OPENED AT LBS.
-PRESSURE
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCTD
2. DID NOT OPEN
El
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
[I
DISC -------------
El
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
---
UPPER -------------------------
El
I
SEAT -------------
0
SEAT -------------
0
LOWER ----------------------
E3
R
DIAPHRAGM --------
0
DIAPHRAGM --------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
El
OTHER, DESCRIBE --E]
UPPER -------------------------
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT ' LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
'REMARKS:
THE ABOVE I REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED By P3 OF ct7,V DATE
0 PAIRED BY DATE
(INAL TEST PERFORMED BY OF DATE
r-
L
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
6r- &DMOMD-S
,1AME OF PREMISES e(5 AT'
SERVICE ADDRESS 4 (6 57 X) D t7 I PA L tj t-
OCATION OF DEVICE E
.)EVICE: WATT-5 0 7
Manufacturer Model Size Serial No.
-,INE PRESSURE AT TIME OF TEST 12-(.1 LBS.
:DRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
'INITIAL
1. LEAKED
El
I . LEAKED
0
1. OPENED AT 3- 4 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X,
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
0
CLEANED
E3
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
E)
GUIDE ------------
El
SPRING --------------------------
11
p
PIN RETAINER -----
El
PIN RETAINER -----
EJ
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
El
I
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM --------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
C3
OTHER, DESCRIBE --EJ
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
El
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
ccs OF cl?,-y op ,=Z>p7o"jD-s DATE
INITIAL TEST PERFORMED
0 PAIRED BY DATE
1 NAL TEST PERFORMED BY OF DATE
4
E§TTREET FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTM
BACKFLOW DEVICE TEST REPORT
AIAME OF PREMISES PoRT o r- o �j D -5
46 5
SERVICE ADDRESS _At
-OCATION OF DEVICE 0 Cx
)EVICE: C.4_) A 5-10c) R -2-
Manufacturer Model Size 3erial No.
.-INE PRESSURE AT TIME OF TEST 1-Z G LBS.
.r'RESSURE DROP ACROSS FIRST CHECK VALVE
16-m
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 7 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
11
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
ED
E
GUIDE ------------
El
GUIDE ------------
El
SPRING --------------------------
El
P
PIN RETAINER -----
0
PIN RETAINER .....
n
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE PIN --------
13
UPPER -------------------------
I
SEAT -------------
13
SEAT -------------
El
LOWER -------------------------
R
DIAPHRAGM --------
El
DIAPHRAGM — -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
El
OTHER, DESCRIBE --
El
UPPER -------------------------
EJ
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
C'cs
INITIAL TEST PERFORMED BY(!5�4ae,6��, OF C,,7-Y 0(c 4Fbt7vm.0-S DATE 7-/--o'
PAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
9 0 STREET FILE
4
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
'AME OF PREMISES
PoBT- oF- r=- D t-7 om D S
ERVICE ADDRESS 4 6 ti )CM fn I W-4L L-J A-1
_D OC4<-
,_OCATION OF DEVICE
DEV ICE: W4717— -
S. 9 00 1 04n )OR
Manufacturer Model Size Serial No.
i-INE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
El
1. OPENED AT ?. 5— LBS.
TEST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
E__1
CLEANED
0
CLEANED
El
CLEANED
C]
REPLACED:
REPLACED:
REPLACED:
DISC -------------
C3
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
C3
SPRING -----------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
n
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
UPPER -------------------------
El
I
SEAT -------------
El
SEAT -------------
El
LOWER ----------------------
R
DIAPHRAGM --------
El
DIAPHRAGM—
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
13
OTHER, DESCRIBE --EJ
UPPER -------------------------
E3
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
11
CLOSED TIGHT -----
IJ
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY6�(,6 7 1'3
0 F Cl'?' 0 r OLD 170A0 _3 DATE -7-1-
10 PAIRED BY —DATE
FINAL TEST PERFORMED BY OF DATE
0 'S STREET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
0 BACKFLOW DEVICE TEST REPORT
F,
L
1AME OF PREMISES PO il� 1- 0 f-- r-- b r7 0 t4 0 S -
"ERVICE ADDRESS 1-4 d) rl W-4 L (41
-OCATION OF DEVICE --,--)o Cx
)EVICE: WA T-1- s cM0 Z?,O 8,R
Manufacturer Model Size .15eff61_Ro_.
.INE PRESSURE AT TIME OF TEST 1.;Z(cl LBS.
!"RESSURE DROP ACROSS FIRST CHECK VALVE
LIM
CHECK VALVE No.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
1. LEAKED
1:1
1. OPENED AT :?- & LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
�4,
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
C3
CLEANED
E3
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
C3
DISC -------------
El
DISC.UPPER ----------------------
E]
R
SPRING -----------
0
SPRING -----------
E3
DISC.LOWER ----------------------
E3
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
E3
PIN RETAINER .....
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
C3
I
SEAT -------------
El
SEAT -------------
11
LOWER -------------------------
E]
R
DIAPHRAGM --------
[I
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
11
OTHER, DESCRIBE
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
11
REDUCED PRESSUFE
REMARKS:
'THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
c'cs 7P3
INITIAL TEST PERFORMED BY(9�C4,4e*�'�� _ OF Cr?-y or r3Lb/'70)V,0_9 DATE 7-1-&�__
1 PAIRED BY DATE
`INAL TEST PERFORMED BY OF DATE
4
CITY OF EDMONDS —PUBLIC WORKS DEPARTMATREET FILE
BACKFLOW DEVICE TEST REPORT
qAME OF PREMISES Potgr or- Eptv"p 3
S'ERVICE ADDRESS 1-4 6 S' AD h / PAL
'-OCATION OF DEVICE r --Do ct
DEVICE: U J Q -rT- -5
Manufacturer Model Size
ANE PRESSURE AT TIME OF TEST I.;Z(" LBS.
,RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT �?. o2_ LBS.
—PRESSURE
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCrD
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
11
R
SPRING -----------
0
SPRING -----------
1-1
DISC.LOWER ----------------------
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
13
HINGE PIN --------
0
UPPER -------------------------
C3
I
SEAT -------------
0
SEAT -------------
11
LOWER -------------------------
El
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
13
LOWER ---------------
F-1
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
11
REDUCED PRESSU
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE- r
-7-313
INITIAL TEST PERFORMED BYtt4 0 F C / 7- y (j A.Ab,�7,�gp
DATE ,�L-
PAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
N
4
0 STREET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\1AME OF PREMISES POIRT 0(-- F_J'j)N0N3)S
SERVICE ADDRESS 46s- ADMtkAL WA-y
.-OCATION OF DEVICE oce,
)EVICE: (AJATES_ 14 0 _jc�_
Manufacturer Model Size Serial No.
PRESSURE AT TIME OF TEST /�Z (C' LBS.
'RESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
t9,
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
E3
CLEANED
[I
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
El
R
SPRING -----------
El
SPRING -----------
0
DISC.LOWER ----------------------
11
E
GUIDE ------------
El
GUIDE ------------
El
SPRING ----------------- 7 --------
El
P
PIN RETAINER -----
11
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
11
UPPER -------------------------
0
I
SEAT -------------
11
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM-; -------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER -------------------------
Cl
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
I
El
CLOSED TIGHT -----
I
0
REDUCED PRESSURE
I
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BtJQ�� OF Cr-r y o F &b/,7o Ai P _S DATE
0, PAIRED BY —DATE
FINAL TEST PERFORMED BY OF DATE
"REET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTM&I"
0 BACKFLOW DEVICE TEST REPORT
IAME OF PREMISES PORT OFEDMONDS
SERVICE ADDRESS 4 (o D PT ( 0A L (A I A"-/
�_OCATION OF DEVICE Do C I.< -
DEVICE: Li A -rr-&
Manufacturer Model Size Serial -No.
4
i
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
El
I . LEAKED
11
1. OPENED AT 3. 9 LBS.
—PRESSURE
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
JK
REDUCED
2. DID NOT OPEN
0
CLEANED
11
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
P
PIN RETAINER
C3
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
UPPER -------------------------
C]
I
SEAT -------------
El
SEAT -------------
0
LOWER -------------------------
El
R
DIAPHRAGM --------
El
DIAPHRAGM-; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
El
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
—PRESSURE
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
11
REDUCED
ff vu .1 w1m
THE ABOVE REPORT IS CERTIFIED TO BE TRUE- C'C,5 1 2,33
INITIAL TEST PERFORMED BY&4 OF ciry or.apt7omos DATE 7-
CPAIRED BY DATE
AL TEST PERFORMED BY OF DATE
1414 i
I . 0 0 STREET FILE
4
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1AME OF PREMISES PORT 0(-- &-bt-701UQ3
)ERVICE ADDRESS 1465- /--)Dt7(k2AU W&I
-OCATION OF DEVICE L o ct<
)EVICE: tl-)A T-7--,Zl 90c) O�4 �2-70 R�;-
Manufacturer Model Size Serial No.
-INE PRESSURE AT TIME OF TEST LBS.
ORESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
1 . LEAKED
0
1. OPENED AT 3. 0 LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
X
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
El
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
11
PIN RETAINER -----
I-]
DIAPHRAGM, LARGE
A
HINGE PIN --------
E3
HINGE PIN --------
El
UPPER -------------------------
E3
I
SEAT -------------
El
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
D
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
11
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: 103
DATE
INITIAL TEST PERFORMED BYO����' OF C-f 7- Y OF EZ/7QAd/)-3 _7
PAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
0
STREET FILE
E
4
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
IAME OF PREMISES PO A 7- C(—_ E Z t I �"
.')-ERVICE ADDRESS 46S' 401 PitkAt— WAY
m X) 0 cj<
OCATION OF DEVICE
)EVICE: 60A ]I--S (�o 0 4A.� 7() R
Manufacturer Model , Size Serial' No.
I Z r.
:..INE PRESSURE AT TIME OF TEST LBS.
...) RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
'INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
0,
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
El
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM --------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: ccS ;7.oj
INITIAL TEST PERFORMED BY .4 OF C/ 7/ DATE 7—/—jT.L-
kPAIRED BY DATE
NAL TEST PERFORMED BY OF DATE
0
4
STREET FILE
CITY OF EDMONDS —PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
iAME OF PREMISES PoiRr or- a3>"o"jp_s
"ERVICE ADDRESS
'�.00ATION OF DEVICE 2)o c(<
DEVICE: (4-)A T7-_ S 1?0C) 0!4 -z -70 R
Manufacturer Model Size Serial No.
..INE PRESSURE AT TIME OF TEST LBS.
)RESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT ;) . (� LBS.
TEST
REDUCED PRESSURE
2. CLOSED TIGHT
2. CLOSED TIGHT
X
2. DID NOT OPEN
0
CLEANED
11
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
R
DISC.UPPER ----------------------
11
R
SPRING -----------
0
SPRING -----------
El
DISC.LOWER -----------------------
E3
E
GUIDE ------------
El
GUIDE ------------
11
SPRING --------------------------
Cl
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
E3
---
UPPER -------------------------
El
I
SEAT -------------
C1
SEAT -------------
R
LOWER ----------------------
E3
R
DIAPHRAGM --------
0
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
El
OTHER, DESCRIBE
El
UPPER -------------------------
0
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
REMARKS:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE: &-3
INITIAL TEST PERFORMED B��
OF C/ry ar- jC-,b1wAJDS DATE
PAIRED BY DATE
INAL TEST PERFORMED BY OF DATE
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES PC) /� - F, c" (.'- C.) Ig T) s ___
_:RVICE ADDRESS m I I? I � L - e
)CATION OF DEVICE
:VICE: w"AM C) i-')
Manufacturer Model Size Serial No.
7 0*
INE PRESSURE AT TIME OF TEST /2L-', LBS.
ZESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
�ITIAL
1. LEAKED
0
1. LEAKED
El
1 . OPENED AT lz� JBS.
1.0
TEST
2. CLOSED TIGHT
CLOSED TIGHT
g_
---- REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC --- ---------
0
DISC.UPPER ----------------------
D
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
13
GUIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
0
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE PIN --------
0
UPPER ----------------------
I
SEAT -------------
11
SEAT — ----------
11
LOWER -------------------------
C3
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C1
OTHER, DESCRIBE --E]
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
NITIAL TEST PERFORMED BYC� -0 F
DATE
,rDAIRED BY DATE
_-m
W AL TEST PERFORMED BY OF DATE
STREET FILE
CITY !!'bEDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
JiE OF PREMISES
:RVICE ADDRESS
)CATION OF DEVICE
VICE: c7c, C jLL
Manufa�turer Model Size Serial No.
[NE PRESSURE AT TIME OF TEST 2— (-:-1 LBS.
?ESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
1ITIAL
1. LEAKED
C3
1. LEAKED
13
1. OPENED AT L B S .
TEST
2. CLOSED TIGHT
Q-
-2".' CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
DISC -------------
0
REPLACED:
DISC -------------
El
REPLACED:
DISC.UPPER ----------------------
C1
R
SPRING -----------
C3
SPRING -----------
0
DISC.LOWER ----------------------
13
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
C1
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
ED
HINGE PIN --------
E3
UPPER -------------------------
0
I
SEAT -------------
C3
SEAT -------------
El
LOWER --------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE
UPPER -------------------------
0
LOWER --------- 7 -----
E3
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIE TO BE TRUE:
OF
DATE
By-
NITIAL TEST PERFORMED
,CPAIRED BY DATE
WAL TEST PERFORMED BY OF DATE
�7� r- T
STR L i FILE
CITY OPEDMONDS -- PUBLIC WORKS 410PARTMENT
I-
Li
BACKFLOW DEVICE TEST REPORT
,,ME OF PREMISES R��M- ocz
'RVICE ADDRESS
)CATION OF DEVICE
�VICE: 2- -7 p cz 2—
Manufacturer Model Size Serial No.
NE PRESSURE AT TIME OF TEST LBS.
ZESSURE DROP ACROSS FIRST CHECK VALVE
12 (,--, LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
41TIAL
1. LEAKED
0
1. LEAKED
1]
1. OPENED AT B S .
TEST
2. CLOSED TIGHT
[1
2. CLOSED TIGHT
0 �2.
REDUCED PRESSURE
DID NOT OPEN
CLEANED
1:1
CLEANED
El
CLEANED
El
REPLACED:
REPLACED:
REPLACED:
DISC -------------
El
DISC -------------
El
DISC.UPPER ----------------------
El
R
SPRING -----------
SPRING -----------
El
DISC.LOWER ----------------------
E3
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN ---------
0
HINGE PIN --------
0
UPPER -------------------------
C3
I
SEAT -------------
11
SEAT -------------
C1
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM - -------
11
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE --
C3
OTHER.- DESCRIBE
UPPER ---- 7 ---------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSUWE-
EMARKS:
HE ABOVE REPORT IS CERTIFIE TO B
DATE
OF
NITIAL TEST PERFORMED BY
BY DATE
%iOAL TEST PERFORMED OF DATE
b I HUT FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
�ME OF PREMISES
:RVICE ADDRESS LI- (ffl-, 'l-
)CATION OF DEVICE
-:VICE: �0 4TT7�
Manufacturer Model fli z e SeriAl- No.
INE PRESSURE AT TIME OF TEST 12-C, LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
.0
1. LEAKED
El
I OPENED AT LBS.
TEST
2. CLOSED TIGHT
0-2.
CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
C3
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
;7
DISC -------------
0
DISC -------------
El
DISC.UPPER ----------------------
Cl
R
SPRING -----------
Cl
SPRING -----------
0
DISC.LOWER ----------------------
ED
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
0
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
13
HINGE PIN --------
Cl
UPPER -------------------------
0
1
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM- ------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
El
OTHER, DESCRIBE --El
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT---
El
CLOSED TIGHT -----
11
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:-"._.
OF
NITIAL TEST PERFORMED DATE
"-'PAIRED BY DATE
il�AL TEST PERFORMED BY OF DATE*
a STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
N,
BACKFLOW DEVICE TEST REPORT
�ME OF PREMISES po �)' - /
Jb
-'RVICE ADDRESS f -7 J P
)CATION OF DEVICE
-:VICE:
Manufacturer Model Size Serial No.
INE PRESSURE AT TIME OF TEST LBS.
ZESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
0
1. LEAKED
El
1 ._-OPENED AT �a" � �-
TEST
2. CLOSED TIGHT
M--f'
CLOSED TIGHT
-LBS.
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
C3
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C3
R
SPRING -----------
0
SPRING ------------
0
DISC.LOWER ----------------------
C3
E
GUIDE ------------
E3
GUIDE ------------
El
SPRING ---------------------------
C3
P
PIN RETAINER -----
11
PIN RETAINER -----
E3
DIAPHRAGM, LARGE
A
HINGE PIN --------
11
-HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
C1
R
DIAPHRAGM --------
11
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER ------------ -------------
0
LOWER ---------------
C3
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
7
TEST
CLOSED TIGHT -----
E3
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED//TO BETRUE: -Z
NITIAL TEST PERFORMED B� 5.7- 6F
DATE
C-PAIRED BY DATE
iWAL TEST PERFORMED BY OF DATE
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES
_:RVICE ADDRESS
)CATION OF DEVICE
7 V T7
- ICE: L'<_) -.) 10
Manufacturer Model
fNE PRESSURE AT TIME OF TEST LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
�ize erial No.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
0
1. LEAKED
El
I . OPENED AT - (::;� LBS.
FEST
2. CLOSED TIGHT
CLOSED TIGHT
[6--1
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
CJ
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
13
DISC.UPPER ----------------------
C3
R
SPRING -----------
C1
SPRING -----------
0
DISC.LOWER ----------------------
C3
E
GUIDE ------------
11
GUIDE ------------
El
SPRING --------------------------
C3
P
PIN RETAINER -----
13
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
El
UPPER -------------------------
0
I
SEAT -------------
11
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM-;
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
C3
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
11
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIEQ TO BE TRUE:
1r_,, DATE
NITIAL TEST PERFORMED B�'
OF
r[)AIRED BY v DATE
64k TEST PERFORMED BY OF DATE
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES
:RVICE ADDRESS
)CATION OF DEVICE
-VICE:
Manufacturer Model
INE PRESSURE AT TIME OF TEST 1,? C-- LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
Size
LBS.
Serial No. '
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
El
1 . LEAKED
11
1. OPENED AT -, . C, LBS.
TEST
2. CLOSED TIGHT
M--2—
CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
1-3
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
C3
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
El
I
SEAT -------------
11
SEAT -------------
0
LOWER --------------------------
0
R
DIAPHRAGM --------
El
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
11
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
C3
CLOSED TIGHT-----
0
REDUCED PRESSU
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
DATE
NITIAL TEST PERFORMED
v
'DAIRED BY DATE
OAL TEST PERFORMED BY OF DATE
I
0
%TREET FILE
C,ITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES
:RVICE ADDRESS Z!-G�5- A*x>-r-f/
)CATION OF DEVICE (-2
-VICE:
C'4 ) "', � 4) -ID
Manufacturer Model Size Serial No.
(NE PRESSURE AT TIME OF TEST /'? (" LBS.
IESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NIT IAL
1. LEAKED
EJ
1 . LEAKED
13
1. OPENED AT 2 __C� LBS.
TEST
2 CLOSED TIGHT
M---2-
CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
11
CLEANED
C3
REPLACED:
REPLACED:
REPLACED:
DISC --------------
0
DISC -------------
EJ
DISC.UPPER ----------------------
0
R
SPRING -----------
C1
SPRING -----------
0
DISC.LOWER ----------------------
C3
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
13
UPPER -----------------------
I
SEAT -------------
0
SEAT -------------
13
LOWER -------------------------
11
R
DIAPHRAGM --------
0
DIAPHRAGM-; -------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE
11
OTHER, DESCRIBE
UPPER -----------------------
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIER TO BE TRUE:
OF DATE
qITIAL TEST PERFORMED
40AIRED BY DATE
AL TEST PERFORMED BY OF DATE
0
0
r
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
kME OF PREMISES F_1--71_->1(_1011t:p_.Z>
:_RV.10E ADDRESS
)CATION OF DEVICE
--VICE: -2
Manufacturer Model Size Serial No.
INE PRESSURE AT TIME OF TEST LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
4ITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
8--2.
CLOSED TIGHT
Ej�
___ REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
0
r
-,UIDE ------------
El
SPRING --------------------------
0
p
PIN RETAINER
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE PIN --------
El
UPPER -------------------------
0
1
SEAT -------------
C1
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
11
DIAPHRAGM- -------
0
DIAPHRAGM, SMALL
5
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWER ---------------
El
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
NITIAL TEST PERFORMED BY
46A I R E D B Y
AL TEST L PERFORMED BY
OF DATE
DATE'
OF DATE
0
0
ITREET FILE
CITY OF EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES p
0 j, C-- -k 64
:RVICE ADDRESS
)CATION OF DEVICE
'VICE: co":) 5
-ffa—nufacturer Model Size Serial No.
NE PRESSURE AT TIME OF TEST LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
-I
1. LEAKED
0.
1. LEAKED
0
1. OPENED AT 2— __LBS.
TEST
2. CLOSED TIGHT
El
CLOSED TIGHT
0-
1--- REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
�0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
cl
DISC -------------
0
DISC -------------
0
DISC.UPPER ------------- --------
R
SPRING -----------
0
SPRING --- r -------
0
DISC.LOWER ----------------------
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
C3
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE --
El
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
[1
CLOSED TIGHT -----
0
REDUCED PRE SURE
EMARKS:
HE A BOVE REPORT IS CERTIFIED TO BE TRUE:
DATE
&Z �Z
NITIAL TEST PERFORMED BY,.� 1 ---7S 3 OF c" DATE —
WAIRED BY
AL TEST PERFORMED BY OF DATE
0 0
44DMONDS -- PUBLIC WORKS D"R STREET FILE
CITY OF TMENT
BACKFLOW DEVICE TEST REPORT
�ME OF PREMISES (5 S) f 7
7RVICE ADDRESS
)CATION OF DEVICE
:VICE:
Ll
Manufacturer Model Size Se'rial' No.'
[NE PRESSURE AT TIME OF TEST LBS.
IESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT '3, 1
TEST
2. CLOSED TIGHT
E2-
2. CLOSED TIGHT
ID-
-.LBS.
REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
C3
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
11
DISC -------------
El
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
13
GUIDE ----------
0
SPRING --------------------------
0
P
PIN RETAINER -----
C3
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
El
HINGE PIN --------
0
UPPER -------------------------
0
I
SEAT -------------
El
SEAT -------------
El
LOWER -------------------------
C3
R
DIAPHRAGM --------
0
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
s
OTHER, DESCRIBE --
El
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
NITIAL TEST PERFORMED BY(-%& T OF D AT E
FPAIRED BY DATE
%AAL TEST PERFORMED BY OF DATE
a a' §TREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTME
BACKFLOW DEVICE TEST REPORT
iv, il'>
�ME OF PREMISES f___1 T
.RVICE ADDRESS
)CATION OF DEVICE
0
VICE: Z I -
Manufacturer �_odel Size Serial No.
NE PRESSURE AT TIME OF TEST
, , ? c—'—, LBS.
,,ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
I
CHEC� VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
1ITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT LBS.
-EST
2. CLOSED TIGHT
CLOSED TIGHT
m__�
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
C]
R
SPRING -----------
0
SPRING -----------
CJ
DISC.LOWER ----------------------
I]
E
GUIDE ------------
0
GUIDE ------------
El
SPRING --------------------------
13
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE PIN --------
El
UPPER ------------------ 7 ------
0
1
SEAT -------------
E3
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM—
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
11
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
rFINAL
OPENED AT LBS.
FEST
CLOSED TIGHT -----
C1
CLOSED TIGHT -----
0
REDUCED PRESSURE
.-MARKS:
AE ABOVE REPORT IS CERTIFIED TO BE TRUE:
AITIAL TEST PERFORMED BY�Z' 4 1 .11�_A_/'_/1_ �OF —DATE
:-PAIRED BY DATE
_4�
&PAL TEST PERFORMED BY OF DATE
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT'
BACKFLOW DEVICE TEST REPORT
,tME OF PREMISES eo '0 r! f�?
-1
RVICE ADDRESS /- 1- 6 s- , " i- -� I 4r
)CATION OF DEVICE r7
'VICE:
0 16 C-
Manufacturer Model Size Serial No.
"NE PRESSURE AT TIME OF TEST LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
4ITIAL
1. LEAKED
C3
1. LEAKED
0
1. OPENED AT —5, LBS.
rEST
2. CLOSED TIGHT
02r
--2'- CLOSED TIGHT
0—
--� REDUCr—DWSSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
Cl
R
SPRING -----------
0
SPRING -----------
El
DISC.LOWER ----------------------
E3
E
GUIDE ------------
E3
GUIDE ----------
El
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
E3
UPPER -------------------------
0
1
SEAT -------------
0
SEAT -------------
11
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM —
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --
El
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
El
REDU ED PRE SURE
EMARKS:
HE ABOVE REPORT IS CERTIFIEDJO BE. TRUE:
NITIAL TEST PERF
j DATE
-'ORMED BY��,,� OF
FPAIRED BY DATE
JAL TEST PERFORMED BY OF DATE
E§TREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTM
BACKFLOW DEVICE TEST REPORT
,,ME OF PREMISES r'�O 12 T C) k-L- F-�D V-�
'RVICE ADDRESS
)CATION OF DEVICE 7D L)
.'VICE:
Manufacturer Model Size Serial No.
INE PRESSURE AT TIME OF TEST LBS.
�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
0
1. LEAKED
EJ
1 ., OPENED AT LBS.
TEST
2. CLOSED TIGHT
D-
--2' CLOSED TIGHT
6---'
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
El
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
13
DISC.LOWER ----------------------
E3
E
GUIDE ------------
11
GUIDE ------------
0
SPRING --------------------------
C1
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
0
1
SEAT -------------
0
SEAT -------------
El
LOWER -------------------------
0
R
DIAPHRAGM --------
D
DIAPHRAGM-; -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
El
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
NITIAL TEST PERFORMED B�, ('4 OF
FPAIRED BY
k�AL TEST PERFORMED BY OF�
DATE
DATE
DATE
CITY-%DMONDS -- PUBLIC WORKS IWTMENT STREET FILE
m
BACKFLOW DEVICE TEST REPORT
\ME OF PREMISES 0 N Fj
:_RVICE ADDRESS 46 �;_ fl—D r-7 rA_ �_� I f.j-\ 01
)CATION OF DEVICE 'c'C-
r-VICE: 0 2 In
Manufacturer Model Size Serial No.
4
INE PRESSURE AT TIME OF TEST LBS.
,�ESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
NITIAL
1. LEAKED
0
1. LEAKED
El
1. OPENED AT _LBS.
TEST
2. CLOSED TIGHT
2K.
CLOSED TIGHT
Uj,-"
REDUCED PRESSURE
0
2. DID NOT OPEN
CLEANED
0
CLEANED
11
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
13
DISC.UPPER ----------------------
C1
R
SPRING -----------
E3
SPRING -----------
El
DISC.LOWER ----------------------
I--]
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
C3
P
PIN RETAINER
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE PIN --------
0
UPPER -------------------------
1
SEAT -------------
11
SEAT -------------
E3
LOWER ---------------------
R
DIAPHRAGM --------
0
DIAPHRAGM- -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
EMARKS:
HE ABOVE REPORT IS CERTIFIED TO BE TRUE:
NITIAL TEST PERFORMED'BY OF ce*7 y" 4�,. r- DATE
AIRED BY T.7 DATE
AL TEST PERFORMED BY OF DATE
STREET FILE
c I TYqF E DNION DS -- PUBL I C 1.4ORKSO P A RTME"I"!T '
BACKFLOW DEIITI'r ' E
V , � _ -ST REPORT
NAME OF PREMISES
A' 0 Ae 0 041P
SERVICE ADDRESS
�OCATIO4 OF DEVICE
q,43
DEVICE:'
"d Serial 1,10.
Manufacturer ffo 61 Size
LINE PRESSURE AT TIME OF TEST LBS.
PRESSUR�-5ROP ACROSS FIRST CHECK VALVE LBS.
INITIAL
TEST
CHECK VALVE
1. LEAKED
2. CLOSED.TIGHT
i10. I
0
CHECK VALVE NO.
1. LEAKED
2. CLOSED TIGHT
2
0
ZA
DIFFERENTIAL PRESSURE RELIEF Vf�LVE
1 OPEN;ED AT_ L5S.
R E D U'_ E?_ P Rxg�llyff
2. DID NOT o"PEH
CLEANED
11
CLEANED
0
CLEA�IED
REPLACED:
.,",ErLACED:
REPLACErj:'
DISC -------------
0
nisc -----------
0
Disc. IJPPF" ----------------------
R
SPR I NG ---------
0
SPRING -----------
Ej
DIS C. L 0'.,': E R ----------------------
E
IDLE -------
jUT
FJ
(,U I DE ------------
0
SPR I ING --------------------------
p
PlIN REIAINER -----
El
PIN RETAINER -----
0
DIAPHRAGN, LARGE
A
Hlr"GE PI1 -- --------
D
HINGE PIN --------
0
UPPrrR -------------------------
ISEAT
-* ------------
El
SEAT -------------
D
LM.!FR ------------- ------------
R
C --- --------
"A"", "
0
DJAPHRAGM — -------
0
DIAP.HRAGi'l, SNALL i
S
OTHER, DESCRIBE
--I]
OTHER, DESCRIBE --
0
U P p (,-- Rl --------------------------
1, 0 1.! E. R ------------- I_
SPACER, LO,-17R,
SCRT
OTHER, DE IBE
I FINAL
OPEIN'ED AT I LBS.
TEST
CLOSED TIGH T----- 0
CLOSED TIGHT -----
0
REDUCLD PRESSU R E
REMARKS -
THE ABOVE REPORT IS CERTIFIED TO; �BAE_TR
t
INITIAL -TEST PERFORMED BY OF Ep 147 DATE41/"/
DATE
REPAIRE.0 BY —
FINAL TEST PERFORMED BY OF DATE
CERT. MMBER
-7n
I t%
STREET FILE
CITYlk ED(IONDS -- PUBLIC WORKA'PARTMEN'T
BACKFLOt-I DEVICE i[ST REPORT
PIAME OF PREMISES
SERVICE ADDRESS 4'5--'c tla 0711 Y9 4
LOCATIONL OF DEVICE
DEVICE:
Manufacturer'
lopf,
a
e Serial No.
LINE PRESSURE AT TIME OF TEST aKnO LBS.
PRESSURE -DROP ACROSS FIRST CHECK VALVE t LBS.*
CHECK VALVE NO. 1
CHECK VALVE N!O. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
I N I T I A L
1. LEAKED 0
1. LEAKED 0
1. OPENED AT LBS.
TEST
J
2. CLOSED'.TIGHT
2. CLOSED TIGHT
2. DID NOT OPEN
_�k
CLEANED ED
CLEANED El
CLEA�IED
REPLACED:
REPLACED:.
RERLPCED:'
DISC ------------- 11
DISC -------------- 0
DISC. UPPEI� ---------- ------------
R
SPRING ----------- 0
S PR I I'Mi ----------- 0
D I S C. L O.-,E " ----------------------
E
FiUIDE ------------ El
(, U I D E ------------ 0
I
SPR I ING ----- -----------
P
P I N R E T A I NE R ----- 11
PIN RETAINER El
DIAPHRAG,'l, LARGE
A
HINGE P11 -- -------- 171
HINGE PIN -------- 0
UPPER ------------ ------------
ISEAT
-------------- 0
SEAT ------------- 0
LOWER ---------------- 7 ---------
R
DIAPHRAG,"i -------- 11
DIAPHRAGM - ------- 0
DIAPWRA ' GN, Si'-IALL
S
OTHER, DESCRIBE Ll
OTHER, DESCRIBE --El
UPPER ------------- ------------
LOU17 R ------------- I—
SPACER, LOIJ u R
OTIER, DESCRIGE
OPENED AT LBS.
FINAL
_ T
T TES
EST
CLOSED TIGHT—— 0
CLOSED TIGHT ----- 0
REDUCED PRESSUFE
REMARKS-
P.
THE ABOVE REPORT IS CERTIFIED TO BE T E.:
INITIAL -TEST PERFORMED BY OF
tv
REPAIRE-JD BY
FINAL TCST PERFORi'-lED BY OF
CERT. IMBER
f- ES_
�Q Of 47 jft,,�P DATE
DATE
DATE
I / - 1 7 1 n
STREET FIE
CITY q EDMONDS -- PUBLIC WORKSIPARTMENT
BACKFLOW DEVICE VEST REPORT
NAME OFIREMISES'' PS OC 1 4- 0- F !2! 0/v'Q
SERVICE AIDDRESS 415-6 A0,17,16719 er eve
OCATIOU OF CEVICE
- _- �z .2 0 c
DEVICE:
. -nanufacturer
12del S i z e Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURG-DROP ACROSS FIRST ;HECK VALVE aq LBS.
CHECK VALVE NO. 1
CHECK VALVE NOz 2
DIFFERENTIAL PRESSURE' RELIEF VALVE
INITIAL
1. LEAKED ED
1. LEAKED 13
1. OPENED ATZ J,-' ABS.
TEST
2. CLOSED.TIGHT
A
2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEH
CLEANED CD
CLEANED ED
CLEAKED
REPLACED:
REPLACED:.
REPLACED:
DISC -------------- 0
DISC ------------- 0
DISC.UPPEP ---------- ------
R
SPRING ----------- El
S 11 R I N G ----------- 0
PITSC.LOWER --------- ------------
EGUIDE
------------ 0
(,U I DE ------------ 0
s P R I G ---------------------------
p
PIN RETAINER ----- 0
PIN RETAINER 0
DIAPHRAGiH, LARGE
A
HINGE PIN -------- D
HliNGE PIN -------- 0
Ll P PER ------------- I ------------
SEAT--------------- ED
SEAT ------------- 0
L 0 1,-! E R -------------------------
R
DIAPHRAGt! -------- 0
DJAPHRAGM - ------- F]
DIAPHRAGI'll, S�-IALL
S
OTHER, DESCRIBE --0
OTHER, DESCRIBE --ED
UPPER ------------ 2 1 ------------
1- Olv! E R ----------------
SPACER, LOWER
OTHER, DESCRIBE
I FINAL
OPENED AT LBS.
TEST
CLOSED TIGH T ----- 0
CLOSED TIGHT ----- 0
REDUCED PRrSSU i RE
REMARKS,,
THE ABOVE REPORT IS CERTIFIED TO BE T E:
7��, ��
INITIAL -TEST PERFORMED BY 0 F 1711vg daQ lar DATEWA451-
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
CF,RT. IMBER /J-V
19
I / 7f)
CITY OF EDNiONDS --. PUBLIC WORKS40EPA 'STREET FILE
BACKFLOW DEVICE IEST REPORT
NAME OF PREM11SES fO
SERV I CE . ADDRESS -A� A o lei)
LOCATIOI,� OF DEVICE n c /kc X
DEVICE:
S i 2 e
-fari7fac-urer' No d el
LINE PRESSURE AT-` TIME OF TEST A- o LBS.
PRESSURE. -DROP ACROSS FIRST CHECK VALVE LBS.
" _; �01_ W-1
Serial No.
CHECK VALVE iNO. I
CHECK VALVE NO. 2
DIFFE!���--i�!Tli'kL--Pl�IESSU;�rL RE.L.IEF VALVE
INITIAL
LEAKED 0
1. LEAKED 0
1. OPE.NFD AT BS.
TEST
2. CLOSED JIGHT P(
2. CLOSED TIGHT
RIDUC_�,
2. DID NOT OPEN
CLEANED 0
CLEANED 0
CLEkl[D
REPLACED:
REP LACED:.
RERLPCED:
DISC ------------- 0
DISC ------------- 0
DISC.UPPER --------- ------------
R
S P R I NG ----------- 0
S P R TING ----------- 0
D I SC. L O',-,*E R -----------------------
E
GUIDE ------------ 0
f,U I DF ------------ 0
s P III 1 11 1 G -------------- ------------
P
PI.N RETAINER ----- 0
PIN RETAINER ----- 0
DIAPHRIAGi'l, LARGE
A
HINGE Pl� -- -------- 0
HINGE PIN -------- 0
LIPPER ------------ 7-7 - - - - - - - - - -
SEAT-------------- 0
SEAT ------------- 0
LOL-,`_-R ------------- ------------
R
DIAPHIAGIli 01
DIAPHRAGM 11
DIAPHRAGN, SNALL
S
OTHER, DESCRIBE 0
OTHER, DESCRIBE -- 0
UPPEi ----------------- ------------
I
LOI-�ER -------------
SPACER, L01,4ER
OTHER, DESCRIBE
711 IIAL
OPEINED A"' LBS.
TE
_ST]
CLOSED TIGH . T----- 0
CLOSED TIGHT ----- 0
ED PP
REDUCE E S S
REMARKS-,
THE ABOVE REPORT IS CERTIFIED TO BE TRU
INITIAL. -TEST PERFORMED By OF z-;qwat/,o_r DATE���-/
DATE
REPAIRE.0 BY
FINAL T-L-ST PERFORl'-lED BY OF DNTE
CF,RT. MMBER
-7 rl
I %
C14�F EDNIOINDS -- PUBLIC WORKS11k . P A R T STREET FILE
BACKFLOW1 DEVICE ;'EST REPORT
NAME OF PREMISES OF. tr,4/,o -y
SERV I CEL . ADDRESS 4,00W Zoe A,(— 6�v A
LOCATION' OF DEVICE
DEVI . C E
Manuf a cturer'
0
f,16d e I Size Sol ial No.
LINE PRESSURE AT TIME OF TEST a C-) LBS.
PRESSURE -DROP ACROSS FIRST CHECK VALVE LBS.
CHIECK VALVE
iNO. 1
CHECK. VALVE [110. 2
DIFFERENTIAL PPESSURE-RELIEF VALVE
INITIAL
I LEAKED
13
1. LEAKED
0
1.
OPENED AT 77.j'_ ''LBS.
TEST
1-10
RLDUCt-777M�UE
2. CLOSED.TIGHT
2. CLOSED TIGHT
2.
DID NOT OPEi'l
CLEANED
CJ
CLEt"INED
0
CLEA�
.-IED
REPLACED:
REPLACED:
REPLACED:
DTSC ---------
[I
Disc -------------
Ej
Disc. uppr.R,
L - ---------------------
R
SPRING -----------
El
SPRING -----------
0
D I S C. L O�,.: ER --------- ------------
E
GU I DEL ------------
11
QIDE ------------
0
s Pr' I NG ------------- ------------
p
PIN RETAINER -----
1:1
PIN RETAINER -----
0
DIAPHRAGN, LARGE
A
HliNGE P11 -- --------
1-1
HINGE PIN --------
0
UPPER ------------ ------------
I
SEAT -* ------------
0
SEAT -------------
11
LOWER --------------------------
R
DIAPHRAG,"i --------
0
D'IAPHRAGM --------
F-1
DIAPHRAGi'l, Si`IALL I
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPEF --------------- ------------
Lol.!ER ------------- I_
SPACER, L01-41R
OTHER, DESCRIBE
FINAL
ED AT LBS.
0 P E N"L I
TEST
CLOSED TIGHT ----- 0
CLOSED TIGHT -----
El.
R E D U C E L RESSU ! R E
REMARKS-
0.
THE ABOVE.REPORT IS CERTIFIED TO BE TRUE:
INITIAL -TEST PERFORMED By OF
.# . DATE
REPAIRE..D BY —
FINAL TLEST PERFOR1'-1ED BY OF DATE
cc
CERT. N�MBER
CITY OF EDNiOINDS -- PUBLIC WORKS E I PASTREET FILE
BACKFLOW DEVICE i'[ST REPORT
NAME OF' PREMISES tw o
SERVICE 'ADDRESS
LOCATIO4 OF DEVICE Y c
DEVICE:'
Model a I o
�;,lanuf_a'cturer' Size
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE -DROP ACROSS FIRST CHECK VALVE LBS.
r
CHECK VALV
NO. 11
CHECK VALVE H�O.
2
DIFFEREINTIf.0 PRESSUP,FV'RELIEF VALVE
INITIAL
1. LEAKED
13
1. LEAKED
0
1. OPEi,!FD AT62 L B S
TEST
2. CLOSED TIGHT
2. CLOSED TIGHT
---
REDUCED PRESSUE
2. DID NOT OPEN
CLEANED
0
CLEANED
EJ
CLEA.'IED
REPLACED:
REPLACED:.
REPLACED:
D i S C -------------
0
Disc -------------
13
DISC. UPPER ----------------------
R
SPRINIG -----------
0
SPRING -----------
0
D I SC. L O'.,,� E R -----------------------
E
GU 1 DE ------------
0
r,U I D E ------------
El
s P R 1 11 1 C, --------------- ------------
p
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGN, LARGE
A
HINGE PIN --------
0
HIINGE PIN --------
0
UPPER --------------------------
I
SEAT - - - - - - 7 ------
El
SEAT -------------
L
L 0 R ------------- ------------
R
DIAPHRAGt! --------
[I
DIAPHRAGM --------
0
DIAPHRAGtI, SNALL
S
OTHER, DESCRIBE
11
OTHER, DESCRIBE
U P P I- R, - - - - - - - - - - - - 7 ; - - - - - - - - - - - -
1-01 - .!ER ------------- ;
SPACER, LCOJER
OTHER, DESCR13E
171 L.
OPENED AT
[111 TA
TEST
T7_S
CLOSED TIGH T ----- 0
CLOSED TIGHT -----
11
REDUCED PRESSU ! R E
REMARKS;.
THE ABOVE REPORT IS CERTIFIED TO BE R
INITIAL -TEST PERFORMED BY OF I—,O-,VdA1.0 _r DATE,6�X aF/
DATE
REPAIRE.D BY
FINAL TEST PERFORIHED BY OF DATE
CERT. IFMBER
I / -72
CITY OF EDNiONDS -- PUBLIC I,JORKSIEEPAR41:31EET FILE
BACKFLO�-! DEVICF ;-EST REPORT
NAME OF' PREM11SES eQe.,�r Q F
SERVICE 'ADDRESS A.R.,�22 I
LOCATION� OF DEVICE
DEVICE: u) X t,
..Manufactdrer Mbdel Si'ze Serial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE-SROP ACROSS FIRST CHECK VALVE L5S.
c
VALVE
No. I
CHECK VALVE NO.
2
DIFFERE�JIA.L_ I'V"IES SURE' RELIEF VALVE_
INITIAL
____CHE_CK
1. LEAKED
0
1.
LEAKED
0
1 Op-t,!ED A
t: AT iV 'LBS.
TEST
2. CLOSED.TIGHT
2.
CLOSED TIGHT
RE D U ICED VRESSUR.E
2. DID MOLT OPEH
CLEANED
0
CLEANED
0
CLEA�IED
REPLACED:
REPLACED:
RERLACED:'
DISC -------------
0
DISC ----------
0
DISC.UPPER ---------- ------------
R
SPR I NG -----------
11
SPR I NG -----------
Cl
D I SC. t_O1,,l:ER --------- ------------
E
GUIDE ------------
FJ
C, U I D E ------------
0
SPI, I ------------- -------------
p
PlIN RETAINER -----
0
PIN RETAINER -----
0
n
DIAFHRAGN, LARGE
A
HINGE P11 -- --------
0
HINGE PIN --------
0
UPPER ------------ ------------
I
SEAT --------------
El
SEAT --------------
11
LOW�ER ------------ ----------
R
DIAPHRAGti --------
11
DJAPHRAGM1 — ------
0
DIAPHRAGi'l, Scg'�lL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER ------------ ------------
!
1-01 .,!E R -------------
SPACER, LOIJER
OTHER, DESCl-,\'IBE
OPEN'ED AT
FINAL
T'--.S T
CLOSED TIGHT ----- 0
CLOSED TIGHT -----
0
REDUCED PRESSU i R E
REMARKS,
THE ABOVE.REPORT IS CERTIFIED TO BE '1*11UE: -
INITIAL -TEST PERFORMED BY OF f-,Q.-Va V x9 5- D A T E 6 -1,6 -.9
DATE
REPAIRE.0 BY
FINAL TEST PERFORiNED BY OF DATE
CERT. li�MBER
-7 (�
lo
PUBLIC �,JIORKAEPAR�TREET
CITY OF EDNIONDS ILE
BACKFLO�-.' DEVICI ;�EST REPORT
NAME OF PREMISES
SERVICE ADDRESS /1+.0 �121',49kj L ( 'o
LOCATIO�� OF DEVICE 'o do
DEVICE-.*' 0 1/1112? 0- sc
Mbdel S i z e Serial No.
-A)
fla nuf acturer
LINE PRESSURE AT TIME OF TEST LDS.
A,
PRESSURE.-SROP ACROSS FIRST CHECK VALVE low.,
CHEECK VALVE NO. 11
INITIAL I . LEAKED 0
TEST
2. CLOSED.TIGHT
L
CHECK VALVE 1,,10.
1 . LEAKED
2. CLOSED TIGHT
2
0
—DIFFERENTIAL PRESSUPE lRELIEF V�,LVE
1 0 P E IN E D A T j3A LBS.
REDUCED PRESSURE
2. DID NOT OPF�N
CLEANED
0
CLEANED
0
CLEA�-IED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC. UPPER ---------7 ------------
R
SPRING ---------
El
SPR I NIG - - - - - - - - - 7-
0
D I SC. L E R ----------
EGU
I DL E ------------
0
(,U I DE ------------
0
s 1) R 1 11 1 cl -------------- 1 ------------
P
PIlN RE-1AINER -----
El
PIN RETAINER -----
0
DIAr-HRAG,-i, LARGE
A
HINGE PIl -- --------
1-1
HINGE PIN --------
0
UPPER --------------------------
I
SEAT -------------
El
SEAT -------------
L-1
LOI,-!',7R -------------------------
R
DIAPHRAG,"i --------
El
DJAPHRAGM --------
0
DIAPHRAGi'll, S,"IALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE 0
UPPEi --------------- ------------
L OlV! E R ----------------
SPACER,
OTHER, DESCRIIBE
FINAL
OPENED AT * L BS.'
TEST
CLOSED TIGH T --- 0
CLOSED TIGHT -----
0
REDU D P I= !
REMARKS,
THE ABOVE.REPORT IS CERTIFIED TO BE TR"
INITIAL -TEST PERFORMED By OF -5 DAT EJ�X X1
.6
REPAIRED BY DATE
FINAL TEST PERFORIHED BY OF DATE
CERT. - IMBER—C, 6),
4PE r,�,Tl P F
PUBLIC �,J'ORKS :ET Fl,LE
CITY OF EDHiONDS
BACKFLOW DEVICI_ 'EST REPORI
PIAME OF PREMISES 0 10/ 0,Vl-p
SERVICE ADDRESS
LOCATI&+ OF DEVICE
DEVICE:" WArTS
-e Seri'al No.
4,fa6Tfactorer- Model Siz
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE -DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO.
L
DIFFERENTIAL PRESSURE I'LIEF VALVE
INITIAL
I . LEAKED
0
1. LEAKED
0
1. OPEINiED Al__��?C-_�_LLBS.
TEST
2. CLOSr T
E D T . IGH
Ne
11
2. CLOSED TIGHT
REDUICED PRESSU i R I E
2. DID MO�T O!"EH
A
CLEANED
0
CLEANED
11
CLEA�-IED
REPLACED:
",EPLACED:
REPLACED:'
DISC -------------
El
n1sul -------------
0
DISC.UPPEP ----------- I ------------
R
SPRINIG ------------ El
SpRIj.,'G -----------
0
- D I SC. L 0'.,.: E R ---------- -------------
E
r, U I D E ------------
11
(,U I DE ------------
0
SPR I NC -------------- 7 ------------
P
PIN RETAINER -----
0
PINI RETAINER -----
0
n
DIAPHRAGN, LARGE
A
HINGE P11 -- --------
1-1
HINGE PIN --------
El
UPPER ------ ------ ! ------------
I
SEAT -------------
0
SEAT -------------
0
i
L 0 1,` E_ P ------- ----- 7 ------------
R
D I A P H RAGI'li --------
El
DJAPHRAGM -; -------
0
DIAPHRAGN, S,�`IALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPEF --------------- 7 ------------
I- O't-! E_ R ----------------
SPACER, LAIJER
OTHiER, DESCRIBE
FINAL
0 P E N"L D AT LBS.
TEST
CLOSED TIGHT ----- 0
CLOSED TIGHT---
0
REDUCED PRESSU i RE
REMARKS-
01
THE ABOVE.REPORT IS CERTIFIED TO BE TRUk
imu
INITIAL -TEST PERFORMED BY
OF
REPAIRE-jD BY
FINAL TEST PERFORIHED BY OF
CERT. N�MBER CL (-:_ S--,f — /,$_0 .1
DA T E
DATE
DAT E
CITY OF EDMIONDS -- PUBLIC IVIORKS DEPARSTREET FILE
BACKFLO�,,' DEVICE i'[ST REPORT —
NAME OF PREMISES D A-e 0 Al -0
SERV I cE ADDRESS
LOCATIOf . I OF DEVICE
DEVICE:' 04
'lodel e seria
flanufacturb�'
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE, -DROP ACROSS FIRST CHECK VALVE LBS.
C F, ECK VALVE iNO.
I
CHECK VALVE i-110.
2
DIFFERENTIAL—PRIFSSURE RE -LIEF VALVE
INITIAL
I LEAKED
0
1. LEAKED
0
1. OPENED AT_,l LBS.
TEST
ED.TIGHT
2. CLOS'
2. CLOSED TIGHT
RIL--DLJCE,D*PRESSU,R i E
2. DID NOT OPEi'l
CLEANED
EJ
CLEANED
El
CLEA`IED
REPLACED:
REPLACED:
REPLPCED:
DISC -------------
0
Disc -----------
0
DISC.UPPER ---------- ------------
R
SPRING -----------
0
SPRING -----------
0
D I SC. L01,,�'ER ----------------------
E
CIUIDE ------------
11
rU I DE ------------
0
1
SPRING ------------- ------------
p
PI.N RETAINER -----
0
PIH RETAINER -----
0
DIAPHRAG,'l, LARGE
A
HINGE P11 I --------
0
HINGE PIN --------
0
U P P rr-_ R ------------- ------------
1
SEAT -------------
El
SEAT -------------
0
�7p
LOW" ----------------- ---------
R
D I APHRAGt! --------
L�
F) 1 APHRAGM --------
0
DIAPHRAGi'l, Sj�'IALL i
s
OTHER, DESCRIBE
0
OTHER, DESCRIBE --El
UPPER --------------------------
L 0!.-! E R ------------- i—
R
SPACER, LOJ�i
OTHER, DESCR I GE
OPEINED A T LBS.
FINAL
TEST
CLOSED TIGHT----- 0
CLOSED TIGHT -----
0
R E D U C E D—[)—kTS Mr, C
REMARKS,
THE ABOVE.REPORT IS CERTIFIED.10 T E
RUE
INITIAL. -TEST PERFORMED BY OF �&,V,110 S- D A T E
DATE
REPAIRED BY
FINAL T-CST PERFORi'-lED BY OF
CERT. IMBER C
F)ATE
I
STREET FILE
CITY OF EDMiONDS _- PUBLIC 1,.'ORKS DEPARTMEINT
BACKFLOt-! DEVICE i_[ST REPORT
NAME OF'PREMISES
SERVICE ADDRESS eAl eA 4.
LOCATIO1 OF DEVICE
DEVICE:". U) A tP5
�d el Size Serial No.'
Manufacturer
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE -DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE "!0.
1
CHECK VALVE NO.
2
DIFFERI--�11-1,1�L-...Plr'%E_S_SU_l�rL7 RELIEF VALVE
INITIAL
1. LEAKED
0
1. LEAKED
0
1 . OPENED AT.,2, -9 LBS.
TEST
2. CLOSED.TIGHT
2. CLOSED TIGHT
R ED U C E
D C,'.l
2. DID N OT 0' L.
CLEANED
13
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:'
DISC -------------
0
Disc -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRIN'G -----------
0.
DI S C. L 0',,,: E � --------- --------------
E
GU I DE ------------
El
r�UIDE ------------
0
s I'll, I 111c, --------------------------
p
PI.N RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LA'RGE
A
HINGE PIN --------
D
HINGE PIN --------
0
UPPER ------------ -------------
I
SEAT -------------
0
SEAT -------------
L
LOWER ------------- ------------
R
DIAPHRAGt! --------
11
DIAPHRAGM — -------
11
DIfVPH.RACd,i, S�k"IALL I
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER ------- --------
L M." E R ------
SPACER, LCjlJ;.,_R
OTHER, DESCRIBE
L
1 F I IIAL]
OPEND AT LBS.
TE ST
CLOSED TIGH T ----- 0
CLOSED TIGHT ---
REDUCED PRESSO I R' C
REMARKS;.
THE ABOVE.REPORT IS CERTIFIED TO BE 4E-
INITIAL.- TEST PERFORMED BY OF
REPAIRE..Q BY
FINAL TEST PERFORNED BY OF
CERT. IMBER C C,
D AT E 5-Af
DATE
DAT E
1 / 72
'�E P ST
CITY OF EDNiONDS -- PU5�IC IvJORKs TR, EET FILE
BACKFLOW DEVICI i-EST REPORT
NAME OF' PREMISES E
SERVICE ADDRESS Al
LOCATIOf+ OF DEVICE 2T� �__C f; C6
DEVI . C E
- Manufacturer* Model S1 ze Sprial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE.-bROP ACROSS FIRST CHECK VALVE LBS.'
C P, LCIV\ VALVE NO.
I
CHECK___V/kLVE 1110.
2
DIFF-EI)ENTIA.L Pl-.E.SSU!)E RELIEF VfkLVE
INITIAL
1. LEAKED
13
1. LEAKED
0
1. OPEINED AT___2t_2t�--`_LBS.
TEST
2. CLOSED.TIGHT
2. CLOSED TIGHT
K
RE-DUCEL)
L ki:- PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
0
CLEkIED
REPLACED:
REPLACED:
REPLACED:
Disc -------------
0
Disc -------------
0
DISC.UPPER -------------------------
R
SPRING -------------
11
SPRING -----------
0
D I SC. L 0,%� ER --------- -------------
E
riu I D, -- ------------
0
rUIDF ------------
0
SPR I 111G -----
p
P1.111 RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGII, LARGE
A
HINGE P11 -- --------
E
HINGE PIN --------
0
r
LIPPER ------------ ------------
-------------
0
SEAT --------------
11
!rpSEAT
LO! --------------------- ---------
R
D I A P H RA Gs"i --------
[I
01APHRAGM — -------
0
DIAPHRAGN, SMALL
S
OTHER, DESCRIBE
L1
OTHER, DESCRIBE
UPPEF
L01PE R ------------- —
SPACER, L(i',4ER
OTHER, DISCi-,"IBE
--- — — -
FINAL
---------------
OPEN"ED AT LBS.
TEST
CLOSED TIGH T ----- 0
CLOSED TIGHT -----
0
REDUCED PRESSU i R E
REMARKS.-
-4
THE ABOVE REPORT IS CERTIFIED TO BE TRU
INITIAL -TEST PERFORMED BY Z;;�, �T OF
REPAIRE*� BY
FINAL TEST PERFORIHED BY OF
CERT. 1,1�MBER C' C S — /— 15-0
/7—A 4nn A1.0 X D A T E
DATE
DATE
I / - 1 7 I'll
gT
PUBLIC �,JIORKSIPEUR,
FILE
CITY OF ED111ONDS
BACKFLOI-,'
DEVICI i'[ST REPORT
NAME OF' PREMISES
FOfT 0
N
SERVICE 'ADDRESS
Aa ivIZEA
4 W
LOCATIOt I- OF DEVICE
�o
171�5
OF 0,
1
0 76
DEVICE:
flanufafturer'
'0
5.
._T�
lode] Size
M
.
LINE PRESSURE AT TIME OF TEST LES.
PRESSURE, -DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE iNO. I
CHECK VALVE 1110. 2
DIF'_E[)L',lTlAL P"ESSURE RELIEF VALVE
INITIAL
1. LEAKED El
1. LEAKED 0
A A
1. OPENED AT t -_ LES.
TEST
R E D U(" E D" PRESSURE
2. CLOSED.TIGHT
2. CLOSED TIGHT
2. DID NOT OPLEN
CLEANED 0
CLEANED ED
CLEA"IED
-REPLACED':
REPLACED:.
REPLACED:'
DISC ------------- 0
Disc ------------- 0
DISC.UPPFR ----------- ------------
R
SPRlf�IG ----------- El
SPRING ----------- 0
DISC. LO�`ErR ------- : ------------
E
CiUIDE ------------ 11
r,U I DE ------------ 0
S P R I NG - - - - - - - - - - - - - - I - - - - - - - - - - - -
p
PlIN RETAINER ----- ID
PIN RETAINER ----- 11
DIAPHRAG,`!, LARGE
A
H I NG E P I N -------- D
HIINGE PIN -------- 0
UPPER ------------ ------------
I
SEAT -------------- Cl
SEAT ------------- 11
L 0 �.,1'7 R ------------- ------------
R
DIAPHRAGIll -------- 0
DIAPHRAGM — 11
DIAPHIRJACil, S,"'ALL
S
OTHER, DESCR15E 0
OTHER, DESCRIBE --El
UPPER --------------------------
L01,!ER -------------
SPACER, LOIJER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT ----- 0
CLOSED TIGHT ----- El
REDU D kr5_TJ ; R_ C
REMARKS-
0.
THE ABOVE REPORT IS CERTIFIED 0 BE T E.
Y
OF
INITIAL -TEST PERFORNIED B
REPAIREJQ BY
FINAL TEST PERFORi'-lED BY OF
CERT. li�MBER C
Z-�,W CAW I D AT E i--I"l
DATE
DATE.
STREET FILE
CITY OF EDMiONDS -- PUBLIC WORKS E P A R T M'E N T
BACKFLOW DEVICI_ i'EST REPORT
NAME OF PREMISES
SERVICE ADDRESS v
LOCATIP OF DEVICE '�v 10 C A,
DEVICE: '/A S�
Manufacturer' Model
LINE PRESSURE AT TIME OF TEST / , ?'--, 0-D, LBS.
Size Serial Nd.
PRESSURL-DROP ACROSS FIRST CHECK VALVE LBS.'
CHECK VALVE NO.
I
CHECK VALVE MO.
2
DIFFERENTIAL PRESSURE-J'ELIEF VALVE
::LBS.
INITIAL
1 . LEAKED
0
1. LEAKED
0
1. OPEINED AT �?,, o —_
TEST
2. CLOSED.TIGHT
2. CLOSED TIGHT
0
REDUCE�D PRESSU ! RE
2. DID NOT OPEN
CLEANED
El
CLEANED
El
CLEA:IED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC. UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DIS C. Lo�,:El` 7 ------------
E
CiUlDE ------------
11
r,U I DE ------------
0
SPR IN G ------------- 7; - - - - - - - - - - - -
P
PIN RF"INER -----
11
PIN RETAINER --- 7-
0
DWHRAGj�], LARGE
A
HINGE PINI --------
D
HINGE PIN --------
0
UPPER ------------ ------------
1 ',7
I
SEAT -------------
11
SEAT -------------
L-1
LO!-,,-R -------- - -------
R
D111111AG11 11 --------
Ll
11APHIA111 -------
0
DIAPHRAG'l, Sl�-!IALL
S
OTHER, DESCRIBE
I]
OTHER, DESCRIBE
UPPER -------------- ------------
------------:
S P 'Al C E R , L 0'. 4 E R
OTHER, DESCR I B
1 FINAL
OPENIED AT LBS.
TEST
CLOSED TIGH T ----- 0
CLOSED TIGHT -----
0
REDUCED PRESSUR
REMARKS,;
THE ABOVE.REPORT IS CERTIFIED TO BE TRUE:
INITIAL -TEST PERFORMED By OF
REPAIRE-JQ BY
FINAL TEST PERFORMED BY OF�
CERT. MMBER /0—d
D4f o &,0 5. _DATEjc_/�
DATE
DAT E
STREET FILE
OF EDNIONDS -- PUBLIC W Ilk
C, I T Y ORKS " P A R T M E NT
NAME OF PREMISES PC34
SERVICE ADDRESS
BACKFLOW DEVICE I[ST REPORT
4— (10141
LOCATIO1 OF DEVICE ;,"S"
.. O� 'o
#9V2!7,b 940
DEVICE:
10.
s i z e
fla n u f a c t u r e r
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE. -DROP ACROSS FIRST CHECK VALVE 1_7 LBS.'
CHECK VALVE NO.
I
CHECK VALVE NO. 2
L R�SSURE _R':LIE�' VALVE
DIFFEI)f- NTIAL P"L
INITIAL
1. LEAKED
11
1. LEAKED
0
1. OPEINED AT-Z, LBS.
TEST
2. CLOSED.TIGHT
-
2. CLOSED TIGHT
REDUCED PRESSURE
2.. DID NOT OPEN
CLEANED
0
CLEANED
0
CLEA.'IED
REPLACED:
REPLACED:.
IREPLACED:'
Disc -------------
0
DISC -------------
0
DISC.UPPEP ----------------------
R
SPRING -----------
11
SPRItIG -----------
0
D I SC. LU,,!E� ---------- 7 - - - - - - - - - - - -
E
CIUIDE ------------
El
r�UIDF ------------
0
SPRING --------------------------
P
PIN RE-TAINER -----
0
PIN RETAINER -----
0
DIAPHRAGN, LARGE
A
HINGE PIN --------
E
HINGE -PIN --------
0
UPPER ------------- : ----------
I
S EAT -------------
0
SEAT -------------
0
7p
L 0 1,.! ----------------- ---------
R
IIAIIllt"%G,",
0
D-11APHRAGM --------
0
DIAPHRAGi'l, SiIALL i I
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE
UPPER ------------- ! ------------
L Olv! E R ------------- 1 -
SPACER,
OTHER, DESCRIBE
OPENIED Al LBS.
CLOSED TIGHT ----- 0
CLOSED TIGHT -----
0
L
REDUCED PRESSUP,
REMARKS;,
THE ABOVE REPORT.IS CERTIFIED TO BE
INITIAL -TEST PERFORMED By 0 F ol;60 _5' DA T E,3:1-4� 41
DATE
REPAIRE.0 BY ---
FINAL T-EST PERFORI'IED BY OF DATE
CERT. 14�MBER
-7 Q
, , N
-- 14
0 - �-/ (-e ; - --5 L 0 F, I / I C-
STREET FILE
CITY OF EDMON..DS PUBLIC WORKS,,DEPARTMENT
BACKFLOW DEVICE TEST REP6RT
IE OF PREMISES PORT OF FDMONDS
�VICE ADDRESS 456 Admiral Way Edmonds, Wash
:ATION OF DEVICE Dock E
VICE: Watts goo lit 427087
Manufacturer Fo—del Size Serial No.
NE PRESSURE AT TIME OF TEST 120 LBS.
:-SSURE DROP ACROSS FIRST CHECK VALVE 89,5, LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
El
1. LEAKED
E3
1. OPENED AT LBS.
EST
2. CLOSED TIGHT
C�
-2. CLOSED TIGHT
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
El
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC.LO14ER ----------------------
0
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
ID
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE -PIN --------
C3
UPPER -------------------------
C3
I
SEAT --------------
0
SEAT -------------
0
LO�JER -------------------------
[I
R
DIAPHRAGM --------
[I
DIAPHRAGM-; -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOtIER ---------------
0
SPACER, LO14ER
OTHER, DESCRIBE
INAL
OPENED AT 2,, LBS.
:ST
CLOSED TIGHT -----
CLOSED TIGHT -----
REDUCED PRESSURE
1ARKS:
ABOVE REPORT IS CERTIFIED TO RUE: <-- c5
1TIAL TEST PERFOR lit MED BY 2ML 9 OF Edmonds, Wash DATE 12/1/79
'AIRED BY A DATE zvzi
IAL TEST PERFORMED/BY OF DATE
2�-- 1/73
STREET FILE
CITY OF EDMONDS -- PUBLIC -WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES Pi-,RT OF ED1.10NDS
SERVICE ADDRESS 456 ADMIRAL WAY EDMONDS, WASH
LOCATION OF DEVICE D
DEVICE: WATTS 900
Manufacturer Model !�I_ze
LINE PRESSURE AT TIME OF TEST. 120 LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE 7.1 LBS.
It 427082
�erial No.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE*
INITIAL
1. LEAKED
:Fc]
1. LEAKED
a
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT
Ei
2. CLOSED TIGHT.
0
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
C!r
CLEANED
5?"
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 1:1
DISC -------------
0
DISC.UPPER -----------------------
El
R —
SPRING -----------
El
SPRING -, ----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
p
PIN RETAINER -----
El
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
El
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
El
DIAPHRAGM
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
E3
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT -----
k
CLOSED TIGHT -----
ge
REDUCED PRESSURE
REMARKS:— el-ief w-1ye lep-ks at -all times,
THE ABOVE REPORT IS CERTIFIED Ty0B TRUE:4_-e_5-_/
OF Edmonds, Wash DATE 12/1/70
INITIAL TEST PERFORMED BY
REPAIRED BY DATE
FINAL TEST PERFORME OF D A T F/
P 'v L4/ V
1/73 -
0 STREET FILE '0 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1E OF PREMISES _ Port Of Rdmondp
33
L-1--)
�VICE ADDRESS - . 456 Admiral Way Edmonds,,- Wash
:ATION OF DEVICE Dock H
/ICE: Watts goo
Manufacturer Model Size '5-rial No.
IE PRESSURE AT TIME OF TEST / cl� LBS.
SSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
0
1. LEAKED
I
El
1. OPENED AT LBS.
--ST
2. CLOSED TIGHT
.2. CLOSED TIGHT
/I
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
1)
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
C3
DISC.UPPER ----------------------
[I
R
SPRING -----------
13
SPRING -----------
0
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
11
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE. PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
C3
DIAPHRAGM --------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
INAL
-'ST
CLOSED TIGHT -----
CLOSEDTIGHT -----
REDUCED PRESSURE
11ARKS:- #2 test cock pl�4gged inside of body. could not test.
:- ABOVE REPORT IS CERTIFIED TO RUE:C e <- /
ITIAL TEST PERFORMED BY ; I-&- 1,S-69 OF -Erimmnri DATE.12Z1/79
'AIRED BY DATE
k -
IAL TEST PERFORMED Yjj-/
A/1 OF DATE
1/73
*STREET FILE 09 It -�'3& ck,4 vo 1,/-0L(w7
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1E OF PREMISES Pprt Of Edmonds
�VICE ADDRESS 456-Admiral Way Edmonds, Wash
:ATION OF DEVICE Dock I
�/ICE: Watts 900 lit 427034
Manufacturer Model Size Serial No.
'�E PRESSURE AT TIME OF TEST 120 LBS.
7-SSURE DROP ACROSS FIRST CHECK VALVE 11 .2 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURERELIEF VALVE
ITIAL
1. LEAKED
11
1. LEAKED
0
1. OPENED AT LBS.
EST
2. CLOSED TIGHT
M
CLOSED TIGHT
m
REDUCED PRESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
E3
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
cl
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE.PIN --------
0
UPPER -------------------------
C3
I
SEAT -------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM — -------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
NAL
0 PENED AT 41 LBS.
'ST
CLOSED TIGHT -----
CLOSED TIGHT -----
14
REDUCED PKESSURE
IIARKS
7 ABOVE REPORT IS CERTIFIED TO Bh TRUE:,ccjr- /
ITIAL TEST PE r RMED BY OF Edmondss Wash
'AIRED BY
� A L T E S T P E R F 0 R M EJO/ B Y 17r-.-- OF
DATE 12/1/79
DATE
.DATE
K
1/73
-4
STREET FILE 40 331a c`3`11t�j 6`7'�
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
IE- OF PREMISES I?or:t
�VICE ADDRESS - . 456 Admirnl W2y EdmQn Wash
:ATION OF DEVICE Do ck J
,�ICE: Watts 900 427,093
Manufacturer Model Size Serial No.
4E PRESSURE AT TIME OF TEST 120 LBS.
7SSURE DROP ACROSS FIRST CHECK VALVE 3.6 —LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
1
1. LEAKED
EJ
1. OPENED AT_' 2 LBS.
�EST
2. CLOSED TIGHT
0
2. CLOSED TIGHT
k -
_4
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
71
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- E3
DISC -------------
11
DISC.UPPER ----------------------
11
R
SPRING -----------
0
SPRING ----- -----
0
DISC. L014ER ----------------------
ED
E
GUIDE ------------
El
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
13
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
C3
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
C3
LOWER -------------------------
C3
R
DIAPHRAGM --------
0
DIAPHRAGM --------
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C1
OTHER, DESCRIBE --E3
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
I INJ A L
OPENED AT -Z— LBS.
--ST
CLOSED TIGHT -----
CLOSED TIGHT -----
J4
REDUCED PRESSI
IARKS:
ABOVE REPORT IS CERTIFIED TO TRUE:ccs-
ITIAL TEST PERFORMED BY* OF DATE
Edmonds. Wnsh _L_211 /79
.'AIRED BY X /OaOZA, DATE- 111317�
,IAL TEST PERFORM��B&4-r, OF DATE/ Z7
Zj
/ f
1/73
0* STREET'FILE*oF,"�-,,33�oCWm.i(,,-ZUYI,
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLO14 DEVICE TEST REPORT
1E OF PREMISES
'VICE ADDRESS
% 456 Admiral Way Edmonds, Wash
^ATION OF DEVICE Dock K
VICE: wn t t s (1110 lit 4272.11
N a n u f a c t u r e r Flod e I Size Serial No.
NE PRESSURE AT TIME OF TEST 120 LBS.
:-SSURE DROP ACROSS FIRST CHECK VALVE 7.2 LBS.
- CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
�X
I . LEAKED
M
1. OPENED AT 6.9 LBS.
LEST
2. CLOSED TIGHT
C3
CLOSED TIGHT
11
REDUCED PRESSUTE
2. DID NOT OPEN
CLEANED
OEr
CLEANED
10'-
CLEANED
C3
REPLACED:
REPLACED:
REPLACED:
DISC -------------
DISC -------------
tK
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
El
E
GUIDE ------------
0
GUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
DIAPHRAGM -; -------
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
NIAL
OPENED AT LBS.
�ST
CLOSED TIGHT -----
A
-- A
CLOSED TIGHT -----
REDUCED PRESSURE
1ARKS:
ABOVE REPORT IS CERTIFIED TO
MAL TEST PERFORMED BY
0 nf
)AIRED BY 0A n 0-/)
�AL TEST PERFORMED B�/
TRUE: c c!5- /
�16 IS-61 OF Edmondst Wash
41
OF
DATE 12/1/'19
DATE
DATE
1/73
�STREET FILE
3 3 llcllr��l
CITY OF EDMONDS P.UBi.IC WORKS DEPARTMENT
BA*CKFLQW DEVICE FEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE f
DEVICE
��, ll� .. ? I ' . . . — ' 1 .1. .... . S&ial
Matufktu�&- Model S i ze
LINE PRESSURE� AT TIME OF TEST ..LBS.
LBS.
.PRESSURE DROP ACROSS FIRST CHECK VALVE
CHECK VALVE NO.
I
CHECK VALVE NO. 2
-7 - - --------- 7�
DIFFERENTIAL PRESSURE RELIEF VALVE-
INITIAL
1. LEAKED
0
1.
LEAKED
El.
1. OPENED AT LBS.
TEST.:.
2. CLOSED TIGHT
2.
CLOSED TIGHT
RE UCED P ESSURE
2. DID NOT OPEN
CLEANED
0
CLEANED
0
CLEANED
L
REPLACED:
REPLACED:
REPLACED:
DISC
0
DISC
El
DISC. UPPER - - - 7- - - - - - - - - - 7-7 . . . . . .
R
S PF I NG --- -------
0
S P R I N G' � -----------
Q
DISC. L 0.4 E R - ----------
- ----------- 7 , I -.
GIJ I DE ------------
El
GU I DE 7 --------
El
SPR Il'IG - - - - - - - - - - - - 7.7-7 - - - - - - - - - -
F-1
p
'PIN RETAINER
E3
P-IN RETAINER-� ----
0
DIAPHRAGM, LARGE
A
HINGE P-4
0
HINGE PIN
o
UPPER -----
SEAT
0
SEAT -------------
FJ
LOWER
DIAPHRAGM ---
0
DIAPHRAGM
El
DIAPHRAGM, SMALL,
s
QTH DESCRIBE
HER,
0
OTHER, DESCRIBE r�O
UPPER ------ --------
LOI -lE R
SPACER, LOWER
OTHER, DESCRIBE
FINAL
OPENED AT LBS '
TE . ST
CLOSED TIGHT -----
El
CLOSED TIGHTr--
11
REDUCED'PRESSURE
I 7fj
STREET FILE 0 06m"��wol
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1E OF PREIMISES
�VICE ADDRESS 456 Admiral Way Edmonds, Wa.
]ATION OF DEVICE Visitors Float ( Dock)
.1 ICE: Watts goo 427080
Flanufacturer Model Size Serial No.
�E PRESSURE
AT TIME
OF TEST
120 LBS.
:SSURE DROP
ACROSS
FIRST CHECK VALVE
10.2 —LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
El
1. LEAKED
0
1. OPENED AT 2.1 LBS.
-:ST
2. CLOSED TIGHT
(N
CLOSED TIGHT
9
REDUCED PRESSWE
2. DID NOT OPEN
CLEANED
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
11
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
E3
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
rUIOE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -; -------
E3
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
C3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
NAL
OPENED AT LBS.
'.ST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
0
REDUCED PRESSURE
'1ARKS:
ABOVE REPORT IS CERTIFIED TQ BE TRUE:
'TIAL TEST PEPFORMED BY . ..... ",
OF Edmonds, We.
'AIRED BY
iAL TEST PERFORMED BY OF
I
DATE 12-1-79
DATE
DATE
1/73
STREET FILE 0 J1 ��b qdmlroa
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
11E OF PREI-11SES Port of Edmonds
�VICE ADDRESS 456 Admiral Way
:ATION OF DEVICE Dock N
�IICE: wett S goo
Manufacturer Model
','E PRESSURE AT TIME OF TEST 120_
:-SSURE DROP ACROSS FIRST CHECK VALVE 12.2
Edmonds, Wa.
LBS.
lit 427083
Size Serial No.
LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
11
1. LEAKED
ED
1. OPENED AT 3.1 LB'S.
EST
2. CLOSED TIGHT
[Z
CLOSED TIGHT
x
REDUCED PRESSUFE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
13
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
r-1
R
SPRING -----------
El
SPRING -----------
0
DISC. LOWER ----------------------
El
E
GU I DE ------------
[I
rU I DE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
C3
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
I
SEAT --------------
El
SEAT -------------
0
LOWER --------------------------
[I
R
DIAPHRAGM --------
D
DIAPHRAGM -;
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --E]
UPPER -------------------------
c3
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
INAL
OPENED AT LBS.
'ST
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
El
REDUCED PRESSURE
1ARKS
- ABOVE REPORT IS CERTIFIED TO TRUE. cc
ITIAL TEST PERFORMED BY OF
DAIRED BY
NAL TEST PERFORMED BY OF
I
Edmonds, Wa.
DATE 12/l/79
DATE
DATE
1/73
1E OF PREMISES
-'VICE ADDRESS
:ATION OF DEVICE
STREET FILE 4
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
Port of Edmonds
456 Admiral Way --Edmonds, Wa.
Dock M
VICE: Watts 900 l" 427086
Maiwfacturer Model Ti z _e Serial No.
,,1E PRESSURE AT TIME OF TEST 120 LBS.
7SSURE DROP ACROSS FIRST CHECK VALVE 8.3 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
0
1. LEAKED
0
1. OPENED AT 2.2 LBS.
EST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
Ri
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
C3
CLEANED
R
CLEA"'IED
0
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
0
R
SPRING -----------
C1
SPRING -----------
0
DISC.LOWER ----------------- 7 ----
0
E
GUIDE ------------
0
GUIDE ------------
n
SPRING --------------------------
0
P
PIN RETAINER -----
0
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -; -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
INAL
OPENED AT LBS.
`ST
CLOSED TIGHT -----
0
CLOSED TIGHT -----
El
REDUCED PRESSURE
1ARKS
ABOVE REPORT IS CERTIFIED TO T U E
T
ITIAL TEST PERFOR
/3-11 OF Edmonds, Wa. DATE12/1/79
MED BY
'AIRED B ' Y DATE
4AL TESTPERFORMED BY OF DATE
1/73
11E OF PREMISES
�VICE ADDRESS
CATION OF DEVICE Dock L
VICE: Watts goo lit 427085
Manufacturer Model Size Serial No.
'�E PRESSURE AT TIME OF TEST 120 LBS.
7SSURE DROP ACROSS FIRST CHECK VALVE 8.1 LBS.
3
STREET FILE 0 0 -
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
Port of Edmonds
456 Admiral Way
Edmonds, We..
- CHECK VALVE NO.
I
-CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
11
1 . LEAKED
0
1. OPENED AT 2'e-6 LBS.
EST
2. CLOSED TIGHT
XJ
2. CLOSED TIGHT
4ic
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC -------------
0
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
11
SPRINC ------------
CD
DISC. L014ER ----------------
E
GU I DE ------------
EJ
GUIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
Ll
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
1
SEAT --------------
El
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
D
DIAPHRAGM -I -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE
0
UPPER -------------------------
0
LOWER ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
__-ST
CLOSED TIGHT -----
[1
CLOSED TIGHT -----
0
REDUCED PRESSURE
-1ARKS
ABOVE REPORT IS CERTIFIED TO TRUE: C_ C,5--
ITIAL TEST PERFORMED BY 0 F
'AIRED BY
�AL TEST PERFOR MED BY 0 F.
I
Edmonds, Wa.
DATE 12/1/79
DATE
DAT E
1/ T3
STREET FILE 0
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
11E OF PREMISES Port Of Edmonds
-1 456 Admiral Way
,VICE ADDRESS
:ATION OF DEVICE Dock G
,/ICE: Watts goo
Matiufacturer Model
NE PRESSURE AT TIME OF TEST 120
-_SSURE DROP ACROSS FIRST CHECK VALVE 7.6
Edmonds, Vla.
LBS.
'3-�te . �-6mlf6tj LA�
lit 427089
Size Serial No.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
C3
1. LEAKED
0
1. OPENED AT 4 LBS.
EST
2. CLOSED TIGHT
5d
'2. CLOSED TIGHT
91
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
0
REPLACED:
REPLACED:
REPLACED:
DISC -------------
13-
DISC -------------
0
DISC.UPPER ----------------------
R
SPRING -----------
0
SPRING -----------
0
DISC.LOWER ----------------------
E
GUIDE ------------
[J
GU I DE ------------
ED
SPRING --------------------------
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
C3
HINGE -PIN --------
0
UPPER -------------------------
E3
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
C3
R
DIAPHRAGM --------
C1
DIAPHRAGM — -------
0
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --E]
UPPER -------------------------
E3
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
CLOSED TIGHT -----
0
CLOSED TIGHT ------
E3
REDUCED PRESSURE
IARKS:
ABOVE REPORT IS CERTIFIE RUE: C-
'�UT OV T
OF Edmonds, Wa.. 12/l/79
ITIAL TEST PERFORMED --DATE
'AIRED BY DATE
IAL TEST PERFORMED BY OF -DATE
1/73
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1E OF PREMISES Port of Edmonds
WICE ADDRESS 456 Admiral Way
:ATION OF DEVICE Dock C
.!ICE: MarlUfacturer Watts 900
Model
NE PRESSURE AT TIME OF TEST 120
�-SSURE DROP ACROSS FIRST CHECK VALVE
7.6
Edmonds, Wa
LBS.
'�3(o OcAjAiio-P LJcql_.
lit 42�092,
ize Serial No.
LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
L-J
1. LEAKED
ED
1. OPENED AT 4,2 LBS.
EST
2. CLOSED TIGHT
X
2. CLOSED TIGHT
Z)
REDUCED PRESSUff-E
2. DID NOT OPEN
0
CLEANED
0
CLEANED
0
CLEANED
F-1
REPLACED:
REPLACED:
REPLACED:
DISC -------------
D
DISC -------------
0
DISC.UPPER ----------------------
C1
R
SPRING -----------
0
SPRING -----------
E3
DISC.LOWER ----------------------
0
E
GUIDE ------------
El
GUIDE ------------
C3
SPRING --------------------------
0
p
PIN RETAINER -----
C3
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
C3
1
SEAT --------------
0
SEAT -------------
C3
LOWER -------------------------
[3
R
DIAPHRAGM --------
0
DIAPHRAGM - -------
11
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
C3
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
CLOSED TIGHT -----
[I
CLOSED TIGHT -----
0
REDUCED PRESSURTE
IARKS:
ABOVE REPORT IS CERTIFIED TRUE:C
MED BY;y E TRL
ITIAL TEST PERFOR !e2lt,6 IC&, 1,,"-d OF
"AIRED BY
IAL TEST PERFORMED BY OF
Edmonds, Wa.
DATE 12/1/79
DATE
DATE
1/73
STREET FILE
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
J
1E OF PREMISES Port Of Edmonds
RVICE ADDRESS 456 Admiral Way Edmonds, Wash
�.-ATION OF DEVICE Dock A
VICE: Watts 900 lit 427081
Manufacturer Model —"-- Size Serial No. -
NE PRESSURE AT TIME OF TEST 120 LBS.
ESSURE DROP ACROSS FIRST CHECK VALVE 9.2 LBS.
CHECK VALVE NO.
I
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
E]
1. LEAKED
1. OPENED AT 2.2 LES.
EST
2. CLOSED TIGHT
fj
-2. CLOSED TIGHT
ED
REDUCED PRESSUFE
.
2. DID NOT OPEN
CLEANED
0
CLEANED
P"
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- D
DISC -------------
El
DISC.UPPER ----------------------
0
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
EJ
GUIDE ------------
0
SPRING ---------------------------
0
P
PIN RETAINER -----
11
PIN RETAINER -----
El
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
0
1
SEAT --------------
0
SEAT -------------
0
LOWER -------------------------
0
R
DIAPHRAGM --------
0
DIAPHRAGM -;
R
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --E]
UPPER -------------------------
0
LOWE R ---------------
0
SPACER, LOWER
OTHER, DESCRIBE
I NAL
OPENED AT �). LBS.
--ST
CLOSED TIGHT -----
CLOSED TIGHT -----
I!r—
REDUCZD PRESSURE
1ARKS:
ABOVE REPORT IS CERTIFIED TO
"�=TR E: c
1TIAL TEST FO 11ED BY OF Edmonds, Wash DATE12/1/79
'AIRED BY /
Z� DATE
IAL TEST PERFORMEDAY e, OF DATE
C C
1/73
STREET FILE
CITY OF EDMONDS -- PUBLIC 14ORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
1E OF PREMISES Port Of Edmonds
�VICE ADDRESS "46�6dmiral Way Edmonds, Wash
'ATION OF DEVICE po ck B
/ICE: Watts 900 lit 427090
Manufacturer Model Size Serial No.
4E PRESSURE AT TIME OF TEST 120 LBS.
7SSURE DROP ACROSS FIRST CHECK VALVE 7.8 LBS.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
[TIAL
1. LEAKED
El
1 . LEAKED
0
1. OPENED AT LBS.
:'ST
2. CLOSED TIGHT
gO
2. CLOSED TIGHT
DO
REDUCED PRESSURE
2. DID NOT OPEN
0
CLEANED
C3
CLEANED
D
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- [I
DISC -------------
0
DISC.UPPER ----------------------
r-1
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
0
E
GUIDE ------------
0
rUIDE ------------
0
SPRING --------------------------
0
P
PIN RETAINER -----
El
PIN RETAINER -----
0
DIAPHRAGM, LARGE
A
HINGE PIN -------- 0
HINGE -PIN --------
0
UPPER -------------------------
C3
I
SEAT --------------
0
SEAT -------------
C3
LOWER -------------------------
ED
R
DIAPHRAGM --------
D
DIAPHRAGM-;
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
0
OTHER, DESCRIBE --
0
UPPER -------------------------
ci
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
INAL
OPENED AT LBS.
_-ST
CLOSED TIGHT -----
CLOSED TIGHT ----- 1K
REDUCED PRESSURE
IARKS:_ Relief valve leaks at all times
ABOVE REPORT IS CERTIFIED TO BE_T�UE: c
/,5-09
ITIAL TEST PERFORMED I,-t— OF
)AIRED BY ;� �' lle_�WA '/ W
4AL TEST PERFORMED/6 OF
Edmonds. Wa.sh.
DATE 12/l/79
PATE 12-1,?Z;?J.
DATE
1/73
1E OF PREMISES
�VICE ADDRESS
:ATION OF DEVICE
0,6 STREET FILE*
CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
PORT OF EDMONDS
Admiral Vlay Edmonds, WAsh
Dock D
/ICE: Watts 900 lit
Manufacturer Model Size
�E PRESSURE AT TIME OF TEST 120 LBS.
!SSURE DROP ACROSS FIRST CHECK VALVE 8.2 LBS.
489091
Serial No.
CHECK VALVE NO.
1
CHECK VALVE NO.
2
DIFFERENTIAL PRESSURE RELIEF VALVE
ITIAL
1. LEAKED
1:1
1. LEAKED
0
1. OPENED AT LBS.
7 ST
-
2. CLOSED TIGHT
-2. CLOSED TIGHT
Eg
REDUCED PRESSURE
-
2. DID NOT OPEN
§p
CLEANED
C3
CLEANED
0
CLEANED
REPLACED:
REPLACED:
REPLACED:
DISC ------------- 0
DISC -------------
0
DISC.UPPER ----------------------
Fl
R
SPRING -----------
0
SPRING -----------
0
DISC. L014ER ----------------------
El
E
GUIDE ------------
El
(,UIDE ------------
0
SPRING --------------------------
P
PIN RETAINER -----
0
PIN RETAINER -----
C1
DIAPHRAGM, LARGE
A
HINGE PIN --------
0
HINGE -PIN --------
0
UPPER -------------------------
E3
1
SEAT --------------
El
SEAT -------------
0
LOWER -------------------------
R
DIAPHRAGM --------
El
DIAPHRACM -;
El
DIAPHRAGM, SMALL
S
OTHER, DESCRIBE --
C3
OTHER, DESCRIBE
0
UPPER -------------------------
LOWER ---------------
SPACER, LOWER
OTHER, DESCRIBE
NAL
OPENED AT 2, LBS.
-ST
CLOSED TIGHT -----
CLOSED TIGHT -----
REDU`CE`D PRESSURE
IARKS
ABOVE REPORT IS CERTIFIED T E TRUE:c C5-1
ITIAL TEST P�RFORMED BY
OF' -Pdmnnds DATE 12/ /79
I'A
)AIRED BY If) A DATE
- D
�AL TEST PE O�7ED W -1/ IV OF ATE/Z7/,6/5, 5�
2
1/73
9 CITREET FILE 0 6
CITY of EDMONDS -- PUBLIC WORKS DEPA.RTMENT .
BACKFLOW DEVICE TEST REPORT.
N AME OF PREMISES pc� V'
SERVICE ADDRESS 41 S-L:
LOCATION Or DEVICE
DEVICE: w ot
-4�z2a
Manufacturer model Size Serial No.
LINE PRESSURE AT TIME OF TEST LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED ..................
1. LEAKED ..................
1. OPENED AT LBS.
TEST
REDUCED PRESSURE
2. Ct.OSED TIGHT .........
2. CLOSED TIGHT .....
2. DID NOT OPEN .........................
CLEANED ....................
CLEANED ....................
CLEANED ....................................
REPLACED:
REPLACED:
REPLACED.
DISC .......................
DISC .........................
DISC, UPPER ............................
0
R
SPRING ....................
SPRING ....................
DISC, LOWER ............................
El
E
GUIDE .................... .
0
GUIDE ......................
0
SPRING ....................................
cj-
P
PIN RETAINER .........
0
PIN RETAINER .........
0
DIAPHRAGM, LARGE
HINGE PIN ................
0
HINGE PIN .................
0
UPPER .................................
0
RSEAT
........................
0
SEAT ........................
0
LOWER ............ ....................
0
S
DIAPHRAGM ............
0
DIAPHRAGM .............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE
0
OTHER, DESCRIBE ....
0
UPPER ................................ .
0
41-2- Tr -sr coc-(< -Dars---s
LOWER ................................
0
J%,�Dr AL-r-OLv E,10,10C�N
SPACIER, LOWER ........................
0
t.,J47F�/Z r-,)ye- 7y-�S7-,
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LOS.
�EST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS: PAI LP—,D -tz,) () G 7,A1 s 7- - m p7- 15=4 0 0 &M WA-TlaIZ Celt7l a. Cf--. 7-" /4-0 L, 0-&
T7F-57 Cc<-t4�-
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED BY 6j��4
REPAIRED BY 666
FINAL TEST PERFORMED BY
OF DATE
v
DATE
OF ��— e��_
DATE
9'46TREET-FILE '0 0
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICEXEST REPORT.
NAME OF PREMISES
0%
SERVICE ADDRESS r)jkA.-(,- &JAV
LOCATION Or DEVICE
DEVICE: --c) o C�)
. Manufacturer model size Serial No.
LINE PRESSURE AT TIME OF TEST LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE c� LBS.
I' CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFEnENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKFD ..................
1. LEAKED ..................
1. OPENED AT --L LBS.
TEST
2. CLOSED TIGHT .........
2. CLOSED TIGHT .........
REDUCED PRESSURE
2. DID NOT OPEN .........................
CLEANED .....................
0
CLEANED .................
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACED.
DISC .......................
0
DISC .......... ..............
m
DISC, UPPER ............................
0
R
SPRING ....................
0
SPRING ....................
C3
DISC, LOWER ................ .............
E
GUIDE ....................
0
GUIDE ......................
SPRING ....................................
P
PIN RETAINER .........
0
PIN RETAINER .........
DIAPHRAGM, LARGE
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
0
RSEAT
........................
0
SEAT ........................
0
LOWER .................................
0
S
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER. DESCRIBE
0
OTHER, DESCRIBE ....
C3
UPPER ................................
0
LOWER................................
0
SPACIER, LOWER ........................
0
OTHER, DESCRIBE ....................
0
FINAL
OPENED AT LBS.
�EST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS:
ABOVE REPORT IS CERTIFIED TO BE TRUE:
2
INITIAL TEST PERFORMED BY OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
OSTREET-FILE
CITY of EDMONDS PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICEIEST REPORT.
NAME OF PREMISES
SERVICE ADDRESS .4sZp Ai)mg-pa-
LOCA TION OF DEVICE F
40�'LL(!�4
t mc C4<
DEVICE': o
Manufacturer model Size serial i�o.
LINE PRESSURE AT TIME OF TEST LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED ..................
1. LEAKED ..................
1. OPENED AT LBS.
TEST
REDUCED PRESSURE
2. Ct.OSED TIGHT .........
CLEANED .....................
2. CLOSED TIGHT .....
2. DID NOT OPEN .........................
CLEANED . .................. ; .................
CLEANED .....................
REPLACED:
REPLACED:
REPLACED.
DISC .......................
c)
DISC ......................... 0
DISC, UPPER ............................
0
R
SPRING ....................
0
SPRING ..................... 0
DISC, LOWER ............................
0
E
GUIDE .................... .
GUIDE ......................
SPRING ....................................
0
P
PIN RETAINER .........
PIN RETAINER .........
DIAPHRAGM. LARGE
A
I
HINGE PIN ................
0
HINGE PIN ................ 0
UPPER .................................
0
RSEAT
........................
0
SEAT ........................ C3
LOWER .................................
0
S
DIAPHRAGM ............
0
DIAPHRAGM ............ 0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER, DESCRIBE 0
UPPER ................................
0
LOWER................................
0
SPACIER, LOWER ........................
0
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
REDUCED PRESSURE
REMARKS:
0ABOVE REPORT IS CERTIFIED TO BE TRUE:
By DATE
INITIAL TEST PERFORMED OF
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
OSTREETTILE
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT.
NAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE "F"
DEVICE: A, 7-r q o C)
Manufacturer Mode/ Size Senai ft.
LINE PRESSURE AT TIME OF TEST LUS.
PRESSURE DROP ACROSS FI FIST CHECK VALVE D LBS.
ICHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFETIENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED ..................
1. LEAKED ..................
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT .........
CLEANED ....................
2. CLOSED TIGHT .....
REDUCED PRESSURE
2. DID NOT OPEN... ..........................
CLEANED ....................................
E3
CLEANED ....................
REPLACED:
REPLACED:
REPLACED.
DISC .......................
0
DISC .........................
0
DISC, UPPER ............................
0
.R
SPRING ....................
0
SPRING ....................
0
DISC, LOWER ............................
E
GUIDE ....................
0
GUIDE ......................
0
SPRING ....................................
P
PIN RETAINER .........
0
PIN RETAINER ......... .
0
DIAPHRAGM, LARGE
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
RSEAT
........................
SEAT ........................
0
LOWER .................................
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACER, LOWER ........................
0
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
!TEST
CLOSED TIGHT ..............
CLOSED TIGHT .............
0
1 REDUCED PRESSURE
REMARKS:
BOVE REPORT IS CERTIFIED TO BE TRUE:
IDA
INITIAL TEST PERFORMED BY
OF DATE
v
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF DATE
I .. . *'**STREET FILE 0
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICETEST REPORT
NAME OF PREMISES .1 ..
C— rz--C> r7 0 N D
SERVICE ADDRESS
LOCATION Or- DEVICE 0
DEVICE': v-) 900 ,2 Z 3
Manufacturer model Sim sergal No.
LINE PRESSURE AT TIME OF TEST 0 LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED ..................
1. LEAKED ..................
1. OPENED AT :? LBS.
TEST
2. CLOSED TIGHT
2. CLOSED
REDUCED PRESSURE
0
.........
CLEANED .....................
0
TIGHT .....
CLEANED ........... ........
0
2. DID NOT OPEN .........................
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACED.
DISC........................
0
DISC .......... ..............
0
DISC, UPPER ............................
0
R
SPRING ....................
0
SPRING ....................
0
DISC, LOWER ............................
1:1
E
GUIDE ....................
0
GUIDE ......................
0
SPRING ....................................
CJ
p
PIN RETAINER .........
1:1
PIN RETAINER .........
0
DIAPHRAGM, LARGE
A
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
C3
RSEAT
........................
0
SEAT ........................
0
LOWER .................................
C3
s
DIAPHRAGM ............
0
DIAPHRAGM .............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE
C3
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACIER, LOWER ........................
0
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
I �EST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS:
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED By 0 F DATE
d
of V
REPAIRED 13Y DATE
FINAL TEST PERFORMED 13Y OF DATE
STREET FILE
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE ADDRESS
LOCA TION OF DEVICE
DEVICE': d
Manufacturer model Size Serial No.
LINE PRESSURE AT TIME OF TEST I? C) LBS.
PRESSURE DROP ACROSS FIRST CHECK VALVE ':/� - 0 LBS.
CHECK VALVE NO. 1
CHECK VALVE NO. 2
DIFFEnENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKED ..................
1. LEAKED ..................
1. OPENED AT 3' LBS.
TEST
2. CLOSED TIGHT
2. CLOSED
REDUCED PRESSURE
0
.........
CLEANED .....................
E)
TIGHT .........
2. IDID NOT OPEN .........................
CLEA14ED ....................................
0
CLEANED .................... C1.
REPLACED:
REPLACED:
REPLACED.
DISC .......................
0
DISC .......... ..............
M
DISC -UPPER ............................
C3
R
SPRING ....................
0
SPRING ....................
0
DISC, LOWER ............................
0
E
GUIDE ....................
0
GUIDE .....................
m
SPRING ....................................
0
P
PIN RETAINER .........
0
PIN RETAINER .........
0
DIAPHRAGM, LARGE
A
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
0
RSEAT
........................
0
SEAT ........................
0
LOWER .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
C3
DIAPHRAGM, SMALL
OTHER, DESCRIBE
0
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER ................................
1:1
SPACEn. LOWER ........................
0
OTHER,'DESCRIBE ....................
0
FINAL
OPENED AT LBS.
I �EST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS -
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INITIAL TEST PERFORMED OF DATE
8 Y �ja�
v
REPAIRED BY DATE
FINAL TEST PERFORMED BY OF . . DATE
-j
STREET FILP
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF rREMISES
SERViCE,ADDRESS
LOCArION OF DEVICE 00,
DEVICE':
Manufacturer model Ske Serial No.
LINE PRESSURE AT TIME OF TEST 11:2C> LIJS.
PnE&c:kJliE DROP ACROSS FIRST CHECK VALVE MmEffnb LBS.
... - — - -:. Z; 3 i Le �--. - - - -: � -1 L. 2--
ICHECK VALVE NO. I
CHE*CK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKLD ..................
1. OPENED AT 7— - LBS.
TEST
REDUCED PRESSURE
2. Ct OSED TIGHT .........
2. CLOSED TIGHT .........
2. DID NOT OPEN .........................
0
CLEANFD ....................
CLEANED ....................
CLEANED ....................................
1:1
REPLACED:
REPLACED:
REPLACED.
DISC .......................
DISC ...... : ..................
DISC, UPPER ............................
0
F
SPRING ....................
SPRING .....................
DiSC, LOWER ............................
0
E
GUIDE ....................
GUIDE ......................
SPRING ....................................
0
P
PIN RETAINER .........
PIN RETAINER .........
DIAPHRAGM. LARGE
I
HINGE PIN ................
HINGE PIN ................
UPPER .................................
C3
RSEAT
........................
0
SEAT .........................
0
LOWE R .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER. DESCRIBE ....
0
OTHER, DESCRIBE ....
0
UPPER .................................
0
LOWER................................
0
SPACIE R. LOWE R ........................
0
OTHER, DESCRIBE ....................
0
FINAL
OPENED AT LBS.
TEST
CLOSED TIGHT ..............
CLOSED TIGfIT .............
C3
REDUCED PRESSURE
RENIARKS-
TIA9 ABOVE REPORT IS CEFtTIFIED TO BE TRUE:
INoi1AL TEST PERFORMED BY —Jv/ OF DATE
REPAIRED BY DATE
FINAL TEST PERFORMEO BY OF DATE
0 0 STREET FILE 0 1*
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
.1, lw
t,
vk
NAME OF rREMISES
SERVICE,ADDREsS
LOCATION OF DEVICE
DEVICE': c*-- v/ z7< �,- 2 9 -2
Man crurer �;odel Size crial No.
LINE PRESSURE AT TIME OF TEST LBS.
PRESSURE DROP AcnOSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFEnENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKFO ..................
1. LEAKED ..................
1. OPENED AT -7 LBS.
TEST
REDUCED PRESSURE
2. CLOSED TIGHT .........
2. CLOSED TIGHT .........
2.- DID NOT OPEN .........................
0
CLEANFD .....................
CLEANED ....................
0
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACED.
Disc .......................
DISC ........................
0
DISC, UPPER ............................
0
R
SPRING ....................
SPRING ....................
0
DISC,, LOWER ............................
0
EGUIDE
....................
GUIDE ......................
0
SPRING ....................................
0
.P
A
PIN RETAINER .........
PIN RETAINER .........
0
DIAPHRAGM. LARGE
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
0
RSEAT
.........................
0
SEAT ........................
0
LOWE R .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL 0
OTHER. DESCRIBE ....
0
OTHER. DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACER, LOWER ........................
C3
OTHER, DESCRIBE .....................
0
fINAL
OPENED AT LBS.
TEST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
I
REDUCED PRESSURE
REMARKS-
ABOvE REPORT IS CERTIFIED TO BE TRUE:
INi i IAL TEST PERFORMED BY At4l OF j r:d: DATE /7:-jd-
2:5
REPAIRED BY 'DATE
FINAL TEST PERFORMED BY OF DATE
STREET FILE* qFW?, f 3:5&
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF P14EMISES
SERVICE,ADDRESS . oc) Z) t7l KALI Loj
—
LOCATION OF DEVICE
DEVICE� g) e:)
Manufacturer
Model sire crial No.
LINE PRESSURE AT TIME OF TEST --/30 LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE !-3— LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKED ..................
1. OPENED AT 5 1 LBS.
TEST
2. CLOSED TIGHT .........
2. CLOSED TIGHT
REDUCED PRESSURE
2.'DID NOT OPEN
0
.........
.........................
CLEANED ....................
CLEANED ....................
CLEANED ....................................
REPLACED:
REPLACED:
REPLACED.
DISC .......................
DISC .........................
DISC, UPPER ............................
0
R
SPRING ....................
SPRING ....................
DISC, LOWER ............................
cl
E
GUIDE .....................
GUIDE ......................
SPR ING ....................................
ci
.P
A
PIN RETAINER
PIN RETAINEn .........
DIAPHRAGM, LARGE
I
HINGE PIN ................
**.-
HINGE PIN ................
UPPER .................................
[3
RSEAT
........................
0
SEAT ........................
LOWER .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER. DESCRIBE ....
C3
UPPER ................................
0
LOWER ................................
13
SPAa R, LOWE R ........................
0
OTHER, DESCRIBE ......................
0
FINAL
%
OPENED AT LBS.
TEST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
REDUCED PRESSURE
REMARKS -
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INi i IAL TEST PERFORMED BY
OF DATE
REPAIRED BY 'DATE
FINAL TEST PERFORMED BY OF DATE
3-36 Adm /�,4
?,qIREET FILE*
CIT DS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF P14EMISES
SERVICE I ADDREgS
LOCATIOpf-�F,DEVICE r-1-04-r
DEVICE': 0 4A- z *11�
Manufacturer Mooel Size
LINE PRESSURE AT TIME OF TEST LIJS
PRESFAME DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKE? .....................
1. LEAKED ..................
0
1. OPENED AT -711 LBS.
TEST
2. CLOSED TIGHT .........
2. CLOSED TIGHT .........
REDUCED PRESSURE
2. DID NOT OPEN
0
.........................
�&EANED .....................
CLEANED .....................
0
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACE'D,
DISC .......................
DICIC .........................
0
DISC, UPPER ............................
0
R
SPRING ....................
0
SPRING ....................
0
DISC, LOWER ............................
E
GUIDE .....................
0
GUIDE ......................
0
SPRING .....................................
P
A
PIN RETAINER .........
0
PIN RETAINER .........
0
DIAPHRAGM. LARGE
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .................................
RSEAT
........................
0
SEAT ........................
0
LOWE R .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPAClER, LOWER ........................
0
OTHER. DESCRIBE ....................
0
FINAL
%
OPENED AT LBS.
TEST
CLOSED TIGHT ...............
0
CLOSED TIGHT .............
REDUCED PRESSURE
RENIARKS-
0 ABOVE REPORT IS CERTIFIED TO BE TRUE:
INiiIAL TEST PERFORMED BY ��v4zi—
OF
),� DATE
REPAIRED BY 'DATE
FINAL TEST PERFORMED BY OF DATE
STREET FILE -3�3�o
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE,ADDRESS;
LOCATION OF DEVICE
DEVICE':
<241.
Manufacturer mode/ ske Scro No.
LINE PRESSURE AT TIME OF TEST :3 /) LIJS.
PR[S.c:t)IiE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKED ..................
1 OPENED AT 5i 65 LBS.
TEST
2. CLOSED TIGHT .........
2. CLOSED TIGHT .........
R EDUCED PRESSURE
2. DID NOT OPEN .........................
0
CLEANED ....................
CLEANED ....................
0
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACED.
DISC.......................
DISC ........................
DISC, UPPER ............................
0
R
SPRING ....................
0
SPRING ....................
DISC, LOWER ............................
0
E
GUIDE ....................
0
GUIDE .....................
SPRING ....................................
0
p
A
PIN RETAINER .........
0
PIN RETAINER .........
DIAPHRAGM. LARGE
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER ..................................
Cl
ASEAT
........................ .
0
SEAT ........................
0
LOWER .................................
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER. DESCRIBE ....
(D
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACIER, LOWER ........................
13
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
�IST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
CD
REDUCED PRESSURE
REMARKS:
ABOVE REPORT IS CERTIFIED TO BE TRUE:
1.8 /1. m-
INi i IAL TEST PERFORMED BY
OF DATE
v
REPAIRED BY 'DATE
FINAL TEST PERFORMED BY OF DATE
NAME OF PREMISES
SERVICE ADDRESS
LOCArION Or DEVICE
DEVICE: 4
Manufocturer
OSTREET FILE 0 6
CITY of EDMONDS -- PU-B,LIC WORKS DEPOTMENT
BACKFLOW DEVICE TEST REPORT
m
mo(jel
LINE PRESSURE AT TIME OF TEST 1130 LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE
LBS.
00 OF
Size Serial No.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
1. LEAKFD ..................
1. LEAKED ..................
1. OPENED AT LBS.
TEST
REDUCED PRESSURE
2. CLOSED TIGHT .........
0
2. CLOSED TIGHT .........
2.* DID NOT OPEN .........................
0
CLEANED ...... * ..............
CLEANED ....................
CLEANED ....................................
0
REPLACED:
REPLACED:
REPLACED.
Disc .......................
0
DISC ........................
DISC. UPPER ............................
0
R
SPRING ....................
0
SPRING ....................
DISC, LOWER ............................
0
E
GUIDE ....................
0
GUIDE ......................
SPRING ....................................
0
P
PIN RETAINER .........
0
PIN FIETAINER .........
DIAPHRAGM, LARGE
I
HINGE PIN .* ................
1:1
HINGE PIN ................
0
UPPER .................................
RSEAT
................ , .......
C3
SEAT ........................
0
LOWER .................................
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
OTHER, DESCRIBE ....
0
LIPPE F% ................................
0
LOWER................................
0
SPALIER. LOWER ........................
0
OTHER, DESCRIBE ....................
0
FINAL
OPENED AT LBS.
�EST
CLOSED TIGHT ..............
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS:
0 ABOVE REPORT IS CERTIFIED TO BE TRUE:
INi i IAL TEST PERFORMED BY OF 73
DATE
f
REPAIRED 13Y 'DATE -7
FINAL TEST PERFORMED By OF DATE 11-24-7
3
4
03TREET FILE
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF P14EMISES � Ria walowrom), fto-1clown
SERV&CE,ADDRESS
LOCATION OF DEVICE
DEVICE':
00 2
Manufacturer model Ske Serial No.
LINE PRESSURE AT TIME OF TEST --t 3 (-) LUS.
PRESSOHE DROP ACROSS FI FIST CHECK VALVE I C) LBS.
CHECK VALVE NO. I
CHECK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKED ..................
1. OPENED AT -2, '? LBS.
TEST
2. CLOSED TIGHT .........
2. CLOSED TIGHT ......
REDUCED PRESSURE
2.'DID NOT OPEN .........................
0
CLEANED ....................
CLEANED ....................
CLE ANED ....................................
C3
REPLACED:
REPLACED:
REPLACED.
DISC .......................
DISC ........................
DISC, UPPER ................. ...........
0
R
SPRING ....................
SPRING .....................
DISC, LOWER .............................
0
EGUIDE
.................... .
0
GUIDE ......................
SPRING ....................................
0
.P
PIN RETAINER .........
0
PIN RETAINER .........
DIAPHRAGM. LARGE
1
HINGE PIN ................
0
HINGE PIN .................
0
UPPER .................................
0
RSEAT
........................
0
SEAT ........................
0
LOWER .................................
0
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER. DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACIER, LOWER .........................
0
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
�CST
CLOSED TIGHT ...............
0
CLOSED TIGHT .............
REDUCED PRESSURE
REMARKS
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INi i IAL TEST PERFORMED BY OF
DATE
REPAIRED 13Y DATE
FINAL TEST PERFORMEO BY OF DATE
9 *STREET FILE 0 10
CITY of--E-DMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
SERVICE, ADDRESS &A L 4i_64V
LOCATION OF DEVICE
DEVICE':
Man facturer mot/c/ S;.-e Scrial No.
LINE PRESSURE AT TIME OF TEST / 3 6�) LIJS.
PRESSUHE DROP ACROSS FIRST CHECK VALVE /c), LBS.
CHECK VALVE NO. I
CHECK VALVE NO.'2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKED ..................
1. OPENED AT LBS.
TEST
2. CLOSED TIGHT .........
1�t
2. CLOSED TIGHT
CX,
REDUCED PRESSURE
2.'DID NOT OPEN
.........
—_ —
.
.........................
____ w
CLEANFD ......................
CLEANED ....................
-- — — —
CLEANED ....................................
C3
REPLACED:
REPLACED:
REPLACED,
Disc .......................
DISC ........................
DISC, UPPER ............................
0
R
SPRING ....................
SPRING ....................
DISC, LOWER ............................
0
EGUIDE
....................
GUIDE ......................
SPRING ....................................
0
P
PIN RETAINER .........
PIN RETAINER .........
DIAPHRAGM, LARGE
A
IHINGE
PIN ................
0
HINGE PIN ................
UPPER .................................
1:3
SEAT........................
0
SCAT ........................
LOWER .................................
0
S
DIAPHRAGM .......... *..
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER. DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACIE R. LOWE R ........................
0
OTHER, DESCRIBE .....................
0
FINAL
OPENED AT LBS.
�EST
CLOSED TIGHT ..............
0
CLOSED TIGHT .............
0
REDUCED PRESSURE
REMARKS-
AROVE REPORT IS CERTIFIED TO BE TRUE:
INioIAL TEST PERFORMED BY OF DATE
REPAIRED BY
DATE
FINAL TEST PERFORMED BY OF DATE
�3-3
*STREET FILE 0 40
CITY of EDMONDS -- PUBLIC WORKS DEPARTMENT
BACKFLOW DEVICE TEST REPORT
NAME OF PREMISES
�Zvja wir'-welaw*
SERVICE, ADDRESS -DOCI< --cMr)-jKAL t-J,41
LOCATION OF DEVICE
DEVICEi Wt
0 0
70
Manufacturer mode/ Size Scrialft. Zo
LINE PRESSURE AT TIME OF TEST 11-0- LIJS.
PRESSURE DROP ACROSS FIRST CHECK VALVE LBS.
CHECK VALVE NO. 1
CHLCK VALVE NO. 2
DIFFERENTIAL PRESSURE RELIEF VALVE
INITIAL
I.LEAKED ..................
1. LEAKED ...... ..........
1. OPENED AT S I& LBS.
TEST
REDUCED PRESSURE
2. CLOSED TIGHT .........
2. CLOSED TIGHT .........
2.'DID NOT OPEN .........................
CLEANFD ...... * ..............
CLEANED ....................
CLEANED ....................................
olREPLACED:
REPLACED:
REPLACED.
DISC.......................
DISC ........................
DISC, UPPER ............................
R
SPRING ....................
SPRING ....................
DISC, LOWER ............................
E
GUIDE ....................
GUIDE . .................... i
SPRING ....................................
P
PIN RE7AINEIR .........
PIN RETAINER .........
0
DIAPHRAGM. LARGE
A
I
HINGE PIN ................
0
HINGE PIN ................
0
UPPER .......... ; ........................
RSEAT
........................
0
SEAT ........................
0
LOWER .................................
s
DIAPHRAGM ............
0
DIAPHRAGM ............
0
DIAPHRAGM, SMALL
OTHER, DESCRIBE ....
0
OTHER, DESCRIBE ....
0
UPPER ................................
0
LOWER................................
0
SPACE R, LOWE R ........................
0
OTHER, DESCRIBE .................
0
FINAL
OPENED AT LBS.
�EST
CLOSED TIGHT ..............
CLOSED TIGHT .............
REDUCED PRESSURE
REMARKS
ABOVE REPORT IS CERTIFIED TO BE TRUE:
INi i IAL TEST PERFORMED BY -- "v- I 1�v I,- OF C_lr\i 0(- DATE
REPAIRED BY Jr--c4l� DATE
FINAL TEST PERFORMED BY OF rt7 1,e.1 DATE
02/2+�Y,%9OZ415:11 FAX 425 774 7837 PORT OF EDMONDS
FAX N01 4257
He,�18-2005 FRI 11:52 AM HWA GEOSCIENCES V\/
I r� 3)o A -A -
005
Ur-o UL
FIELD AND LABORATORY CONCRETE TEST P.EPORT go.,
rX7 AS-Tmc3l.C39.C7B,Cl4�',CI72�C231,Cloro4,Ci231 HWAGEOSCIENCESINC
0 AASHTOT23,T22.'rll9,Tl4l.TI52,TSOD TESTISET #.C-.l
CLIENT: part *f Edmonds--- DATE CAST: 112112005
PROJECT: Floating pier Repiacement. DATE RF-C'D* 1/2'2/2005.
HWA PROJECT No—:2005- ESENT50 BY THIS TEST:
tn—F-.�t;CRIPTION OFC'ONEREI
Pier Decks
CYLINDER AGE I CURIING TPST
I.D. I NOTES DATE
T0-5-0o4-;?3-C.1
7
7/zo/uo
005-004-23-C-1
28
PY/1
005-004-23-C-1
28
2118105
FILEXL
BEAM
AGE T:IEST
AVU)
I*D,
0A:TE
W [)TH
NUMBER
(mm
(d3YG)jT:P /ddl
b (in.)
CY'l- IDIAMETE
T ip�
Y S
0"X11 (inches)
6x12 15-OU
6x12 6.99
6x12 6.00
AVG,
DEPTH
d fln.1
SPAN
L
�� I '
ARSA
im:.� 1
28.27
28-18
28-27
Specifiiect
ST DATA
FRACTUREJ
IQCATIONJ
a (In.)
71=--otherYAselnd;.1jt1`;, 7117-111 ary ter. Led In 3 moist sullaeO cond;llcn using leaftrshim'..
INFO. FROM bUrl-LICK I P,-_- �1.
Supplier Name: Glacier NW Max: Agg, size Cin): 318
CementType' 141
Plant Number, Kenmore Plarit;Kq -
Load VOIUMB Uds); _6
Mix Code / No,; 3250 Curn. Volume (yd 3�
Truck Number: i,-9-35
Tickot Number,
- I r-OC.1 TECH.
I�AX. I COMPR.
LOAD STkENGTH TYPE
GM
GM
M
1 2 3 4 5
M"IMUM US OF- 7ECH,
')U'-U
LOAD -TR TURE
Up I
P flbs) R:sl)
Imum:
71me Batched:.6:1-3,
ArriVal -nme: 7:10
Start unloading: T1.5
End Unloading: Unknown
FIELD TE:5 I UA Time sampled: 7.35
Slump (inches): 4 Specified Slump (min -max)! 'Time Cyl-s Cast"""
Entmined Air(%): 6. 0 Spec(fied Ent. Air (min -max): Z-f 0--
Cast By: _
Conc. Temp. (F): 55 Ambient Air Temperature (F): 50 MoldT _tLWAJPJP
- - I - . ... - r--- 1-.ft-MnVN. 53/71 *,F We!- Plasrfc
Contractor / SubContractor.
Conmte piacernant Method, a1:)9.afL09---
Field test result*, raported to _Eay.Johnson (contraigtor Representative
Field test results reporte-d to (Clientlowners Rep. an Site)
Additanal slump tests on the following b-uckloacls: none
HWA also viru-ally asressed the follmWing truckloads., none
lAdditional air tests an the followIng truckloads! none
Reviewed By:
This ?sport appliess onry to the nerm LavW, and may ba reproducad In full. W11h wdtgs appmval of HWA GE0SC4CNCC5 INC.
02/24,12005,-15:10 FAX 425 774 7837 PORT OF EDMONDS
FAX NO. 4257742114
jM-21-2005 FRI 10:26 An HWA GEOSCIENCES
'19730-64111 Avenue WG-'t, Suite 200 Field Report NO.:
Lynriwmad. WA 98038 [)ate (mffddd1yy)'-
U T*L 42_r,7740108 HWA Projer.1; No."
HWAGEOSCIIENCES INC- Fox. 425-'04-2714 HWA Task NO.:
I Locsiw or Addr-IS Of NOW 79FR��
Narne
Drids Flopting Pler Repla
JJVVA t-jVJCLA IV]
P)ort �. �1�, fi�,'jg i� Represemawe
Deoilln AuLhoritY (engineer or smhite— —8— Pat Pierce
H -r ReF
WA ield
General Contrector c3eneral Convacllw KePrUN011w— Pat Pierce
J Rob King.
. PIELD REPORT
10003
1 . vc_
FR-001
J121/2005
2BOs-04-23
051
SUMMARY OF FIELD TIME SPENT ON PROJECT TODAY:
StartTravel: 0645 NrIved at site: o655 Departed Site: oses End Travel. 0815
ACTIVi BEING INSPECTED: Concrete delivery and placement
ITEM BEING CONSTRUCTED: Floating Pier Deck"
TYPE OF INSPECTION: Periodic The concrete was being placed by tailgallng. Consolidation wan accomplished bY
STATUS AND DETAILS OF PLACEMENT OF mATERIAL: I gment ended after our departure.
screeding. A tDtal of about A yd3 was Placed during our vlslL Concratepac eparf for Set 0-1 for a summary of
HWA INsPECTiON ACTI\jj7IES; RELATED TOTH IS ITEM: See HWNs 'Field and Laboratory Concrete Test R
Inspnotion, and test data.
CONFORMANCE OF THIS rrEM! To the best of tha;nsspectoes knowledge, the Item inspected was found In conformance with approved plans.
i71SCEL ' ous, ACTIVITIES, OBSERVATIONS ANWOR COMMENTS:
RE Relew
HW pj�
TU _ S*- A a gineer or R
Sign d .
37
H A Ild RoprezentIlli
SUMMARY OF UNRESOLVED ISSUES
Report# ItemIt Status
no no There are no outstanding issues at this time-
Thl,. reponshoUld Only be reproduced In liz entirety. Report is not final until dIgned by ��VA field rePresentative and HWA reviewer. Page 1 of I
RECEIVED
CITY OF EDMONDS Noy 0 5 2004
SPECIAL INSPECTION AND TESTING AGREEMENT
eer-i T
?16T"A6 ;VCr_5) PERMIT COUNTER
Theproject at I M-L_ W
N Et __v/ssued under building permit
number cvZW—i�7,15-:Z _ requires special inspection and/or testing per IBC Chapter 17. The
complete list of s�ecial inspections is attached to this document.
BEFORE A PERMIT CAN BE ISSUED: The owner and contractor and special inspector shall complete
this agreement and the attached structural test(s) and inspections schedule including the required
acknowledgements.
APPROVAL OF SPECIAL INSPECTORS: Each special inspector shall be approved by the Building
Official prior to performing any duties or inspections. Each special inspector shall submit Statement of
Qualifications to the Building Official for review. Special inspectors shall display identification when
performing special inspections on site. Special inspection and testing shall meet the minimum requirements
of IBC Chapter 17 and the following:
A. Duties and Responsibilities of the Special Inspector
1. Observe Work
The special inspector shall observe the site work for conformance with the approved (stamped) plans
and specifications and applicable workmanship provisions of the IBC. Architect or Engineer
reviewed shop drawings may be used only as an aid to inspection. Special Inspections are to be
performed on a continuous basis —meaning that the special inspector is on site at all times observing
the work requiring special inspection. Periodic inspections, if any, must have prior approval by the
City based on a separate written plan reviewed and approved by the Building Official and the
engineer or architect of record.
2. Report Non -conforming Items
The special inspector shall bring non -conforming items to the immediate attention of the contractor
and note all such items in the daily field report. Any item not resolved in a timely manner shall be
immediate cause of the special inspector to notify the Building Official of the plan deviation, error,
change or omission. It shall also be the duty of the special inspector to promptly notify the engineer
or architect.
3. Complete Daily Reports
Each special inspector shall complete and sign both the special inspection record and the daily report
form for each day's inspection. These records shall remain at the jobsite with the contractor for
review by the City Building Inspector.
4. Furnish Weekly Reports
The special inspector or inspection agency shall furnish the City with weekly reports of tests and
inspections. The project engineer or architect, and others as designated shall also be copied on
reports. Weekly reports must include the following:
Description of daily inspections and tests made with applicable locations
List of all non -conforming items
Report on status of non -conforming items (resolved or unresolved)
Itemized changes authorized by the Architect, Engineer and City if not included in non-
conformance items.
5. Furnish Final Construction Report
The special inspector or inspection agency shall submit a final signed report to the City stating that
all items requiring special inspection and testing were fulfilled and reported. And, to the best of
L:\TEMP\BUILDING\SpecialInspectionAgreementIBC.doc 7/04
his/her knowledge the project is in conformance with the approved plans and specifications,
approved change orders and the applicable workmanship provisions of the IBC. Items not in
conformance or unresolved items or any discrepancies in inspection coverage, (i.e., missed
inspections, periodic inspection when continuous inspections were required, etc.) shall be specifically
itemized in this report.
B. Contractor Responsibilities
1. Notify the Special Inspector
It is the duty of the contractor to notify the special inspector when work is ready for special
inspection. Note, the items listed on the attached schedule and as noted on the approved plans and
specifications are required to have special inspections. Adequate notice shall be provided by the
contractor so that the special inspector has time to become familiar with the project.
2. Provide Access to Approved Plans
The contractor is responsible for providing the special inspector access to approved plans at,the
jobsite.
3. Retain Special Inspection Records
The contractor is responsible to retain at the jobsite all special inspection records submitted by the
special inspector. These records are to be provided to the City building inspector upon request.
C. City of Edmonds Building Department Responsibilities
1. Approve special inspectors or inspection agencies
The building department shall approve all special inspectors and special inspection requirements.
2. Monitor special inspection and approve weekly reports
Work requiring special inspection and the performance of special inspectors shall be monitored by
the City Building Inspector. His/Her approval must be obtained prior to placement of concrete or
other similar activities in addition to that of the special inspector.
3. Issue Certificate of Occupancy
The Building Official may issue a Certificate of Occupancy after all weekly special inspection reports
including the final report have been submitted and accepted.
D. Owner Responsibilities
The project owner or the engineer or architect of record acting as the owner's agent shall fund
special inspection services.
E. Engineer or Architect of Record Responsibilities
The engineer or architect of record shall include special inspection requirements on the plans and
specifications.
ACKNOWLEDGEMENTS
I have real and agree to comply with the terms and conditions of this agreement.
Date e,/
Owner
- )04Special Inspector Date )C>
General Contractor 41151�a�nL 10�(d zE-�ate Z
City Building Official 4 Date
L:\TEMP\BUILDfNG\SpecialfnspectionAgreementIBC.doc 7/04
SPECIAL INSPECTION AND TESTING SCHEDULE
PRQrCrNAME BU11DING PERM a
PROJECrADDRESS fEinmG�m-mpEcTmAGecy.sncALNspEcTOR
REINFORCED CONCRETE, GUNITE, GROUT AND MORTAR:
rAmm-roto Gnnfte r-r..# U-"..
A e ests
g Tests
Mix Designs
Reidorring Placement
Batch Plant Inspection
Inspect Placing
Cast Samples
4
Pick-up Samples
ICompression
Tests
PRECAST/PRESTRESSED CONCRETE.
1rum rom- scm rre-jens
I AggregatcTests
Reinforcing Tests
Tendon Tests
Mix Designs
Reinforcing Placement
Insert Placement
Concrete Batching
Concrete Placement
Installation Insepction
Cast Samples
Tests
MASONRY:
— Special Inspection Stresses Used
— Preliminary Acceptance Tests (Masonry Units. Wall Prisms)
— Subsequent Tests (Mortar. Grout. Field Wall Prisms)
— Placement Inspection of Units
ADDITIONAL INSTRUCTIONS OR OTHER TESTS
AND INSPECTIONS:
Form completed by-
Tclephone No.: —
STRUCTURALSTEELIWELDING:
— Sample and Test (list specific members below)
— Shop Material Identification
— Welding Inspection 0 Shop 0 Field
— Ultrasonic Inspection 0Sb0P OField
— Iligli-strength Bolting
Inspection
0 Shop 0 Field
0 A325 0
0 A490
— Metal Dock Welding Inspectiori
— ReWorcing Steel Welding Inspection
— Metal Stud Welding Inspection
— Concrete Insert Welding Inspection
FIRE -PROOFING:
— Placenwrit Inspection
— Density Tests
— Thickness Tests
— Inspect Batching
INSULATING CONCRETE:
— Sample and Test
— Placement Inspection
— Unit Weights .
FILL MATERIAL:
— Acceptance Tests
— Placenwitt Inspection
— Field Density
STRUCTURAL WOOD:
— Shm Wall Nailing Inspection
— Inspection of Glu-larn Fab.
— Inspection of Truss Joist Fab.
— Sample and Test Comporicnts
Tide:
Date:
10
A CITY OF EDMONDS -
SPECIAL INSPECTION AND TESTING AGREEMENT
The project at
number requires special inspectil
complete list of speci:;I- inspections is attached to this document.
issued under building permit
and/or testing per IBC Chapter 17. The
BEFORE A PERMIT CAN BE ISSUED: The owner and contractor and special inspector shall complete
this agreement and the attached structural test(s) and inspections schedule including the required
acknowledgements.
1W
rr- 7
APPROVAL OF SPECIAL INSPECTORS: Each special inspector shall be approved by the Building
Official prior to performing any duties or inspections. Each special inspector shall submit Statement of
Qualifications to the Building Official for review. Special inspectors shall display identification when
performing special inspections on site. Special inspection and testing shall meet the minimum requirements
of IBC Chapter 17 and the following:
A. Duties and Responsibilities of the Special Inspector
1. Observe Work
The special inspector shall observe the site work for conformance with the approved (stamped) plans
and specifications and applicable workmanship provisions of the IBC. Architect or Engineer
reviewed shop drawings may be used only as an aid to inspection. Special Inspections are to be
performed on a continuous basis —meaning that the special inspector is on site at all times observing
the work requiring special inspection. Periodic inspections, if any, must have prior approval by the
City based on a separate written plan reviewed and approved by the Building Official and the
engineer or architect of record.
2. Report Non -conforming Items
The special inspector shall bring non -conforming items to the immediate attention of the contractor
and note all such items in the daily field report. Any item not resolved in a timely manner shall be
immediate cause of the special inspector to notify the Building Official of the plan deviation, error,
change or omission. It shall also be the duty of the special inspector to promptly notify the engineer
or architect.
3. Complete Daily Reports
Each special inspector shall complete and sign both the special inspection record and the daily report
form for each day's inspection. These records shall remain at the jobsite with the contractor for
review by the City Building Inspector.
4. Furnish Weekly Reports
The special inspector or inspection agency shall furnish the City with weekly reports of tests and
inspections. The project engineer or architect, and others as designated shall also be copied on
rep orts. Weekly reports must include the following:
Description of daily inspections and tests made with applicable locations
List of all non -conforming items
Report on status of non -conforming items (resolved or unresolved)
Itemized changes authorized by the Architect, Engineer and City if not included in non-
conformance items.
5. Furnish Final Construction Report
The special inspector or inspection agency shall submit a final signed report to the City stating that
all items requiring special inspection and testing were fulfilled and reported. And, to the best of
L:\TEMP\BUILDfNG\SpeciallnspectionAgreementIBC.doc 7/04
his/her knowledge the project is in conformance with the'approved plans and specifications,
approved change orders and the applicable workmanship provisions of the IBC. Items not in
conformance or unresolved items or any discrepancies in inspection coverage, (i.e., missed
inspections, periodic inspection when continuous inspections were required, etc.) shall be specifically
itemized in this report.
B. Contractor Responsibilities
1. Notify the Special Inspector
It is the duty of the contractor to notify the special inspector when work is ready for special
inspection. Notei the items listed on the attached schedule and as noted on the approved plans and
specifications are required to have special inspections. Adequate notice shall be provided by the
contractor so that the special inspector has time to become familiar with the project.
2. Provide Access to Approved Plans
The contractor is responsible for providing the special inspector access to approved plans at,the
jobsite.
3. Retain Special Inspection Records
The contractor is responsible to retain at the jobsite all special inspection records submitted by the
special inspector. These records are to be provided to the City building inspector upon request.
C. City of Edmonds Buildin2 Department Responsibilities
1. Approve special inspectors or inspection agencies
The building department shall approve all special inspectors and special inspection requirements.
2. Monitor special inspection and approve weekly reports
Work requiring special inspection and the performance of special inspectors shall be monitored by
the City Building Inspector. His/Her approval must be obtained prior to placement of concrete or
other similar activities in addition to that of the special inspector.
3. Issue Certificate of Occupancy
The Building Official may issue a Certificate of Occupancy after all weekly special inspection reports
including the final report have been submitted and accepted.
D. Owner Responsibilities
The project owner or the engineer or architect of record acting as the owner's agent shall fund
special inspection services.
E. EnIzineer or Architect of Record Responsibilities
The engineer or architect of record shall include special inspection requirements on the plans and
specifications.
If ACKNOWLEDGEMENTS
I 4gve read aj(d agree to comply with the terms and conditions of this agreement.
Owner
Special Inspector
Date 0
Date 10
General Contractor Q NC- S!EA
ate xg
City Building Official Date
L:\TEMP\BUILDING\SpeciallnspectionAgreementIBC.doc 7/04
CITY OF EDMONDS
SPECIAL INSPECTION AND TESTING AGREEMENT
T he e a under building
oj u C�tr
pir, n mbe UBC Chapter 17
p 7 C
a dWA this document.
BEFORE A PERMIT CAN BE ISSUED: The owner and contractor and special inspector shall
complete this agreement and the attached structural test(s) and inspections schedule including the
required acknowledgments.
APPROVAL OF SPECIAL INSPECTORS: Each special inspector shall be approved by t . he
Building Official prior to performing any duties or. inspections. Each special inspector shall submit
Statement of Qualifications to the Building Official for review. Special inspectors shall display
identification when performing special inspections on site. Special inspection and testing shall meet
the minimum requirements of UBC Chapter 17 and the following:
A. Duties and Resp—muibilities Of -the SMial Ingggg-or
1. Observe Work
The special inspector shall observe the site work for conformance with the approved
(stamped) plans and specifications and applicable workmanship provisions of the LJBC.
Architect or Engineer reviewed shop drawings may be used only as an . aid to inspection. �
§pecial inspections are to be performed on a continuous basis --meaning that the special
!nspector is on site at all times observing the work requiring special inspection. Periodic
inspections, if any, must have p�ioF ap 170val by the City.based on a separate written plan
reviewed and approved by the Building Mcial and the engineer or architect of record.
2. Report Non -conforming Items
The special inspector shall bring nonconforming items to the immediate attention of the
contractor and note all such items in the daily field report. Any item not resolved in a timely
manner shall be immediate cause of the special inspector to notify the Building Official of the
plan deviation, error, change or omission. It shall also be the duty of the special inspector to
promptly notify the engineer or architect.
3. Complete Daily Reports
Each special inspector shall complete and sign both the special inspection record and the daily
report form for each day's inspection. These records shall remain at the jobsite with the
contractor for review by the City Building Inspector.
4. Furnish Weekly Reports
The special inspector or inspection agency shall furnish the City with weekly reports of tests
and inspections. The project engineer or architect, and others as designated shall also be
copied on reports. Weekly reports must include the following:
DeschTtion of daily inspections and tests made with applicable locations
List o all nonconforming items
Report on status of nonconforming items (resolved or unresolved)
Itemized changes authorized by the Architect, Engineer and City if not included in
nonconformance items
5.' Furnish Final Construction Report
The ecial 'inspector or inspection agency shall submit a final . signed report to the'City stating
that NJ items requiring special inspection and testing were fulfilled and reported - And, to the
best of his/her knowledge the project is in conformance with the approved plans and
fications, approved change orders and the applicable workmanship provisions of the
Items not in conformance or unresolved items or any discrepancies in inspection
coverage, (i.e., missed. ins
pections, periodic inspection when continuous inspections were.
required, etc.) shall be specifically itemized in this report.
JUL-27-2004 09:06
14 -
P. 05/06
D. ColLtractor Responsibilities
1. Notify the Special Inspector
it is the duty of the contractor to notify the special inspector when work is ready for special
inspection. Note, the items listed on the attached schedule ad as noted on the approved
plans and specifications are required to have special inspections. Adequate notice shall be
provided by the contractor so that the special inspector has time to become familiar with the
project.
2. Provide Access to Approved Plans
The contractor is responsible for providing the special inspector access to approved plans at
the jobsite.
3. Retain Special Inspection Records
The contractor is responsible to retain at the ' bsite all special inqpection records submitted
by the special inspector. These records am toVe provided to the City building inspector upon
request.
C. all of Edmonds Iftuilding DellartintAt Reso2usaillities
1. Approve special inspectors or Inspection agencies
The building department shall approve all special inspectors and special inspection
requirements.
2. Monitor special inspection and approve weekly reports
Work requiring special in tiOlk erformance of special inspectors shall be
monitored by the City Bui%g - anedtotrh.' Wis/her approval must be obtained prior to
placement ot concrete or other. siUa'rVactivities in addition to that of the special inspector.
3. Issue Certificate of Occupancy
The Building Official may issue a Certificate of Occupancy after all weekly special inspection
reports including the final report have been submitted and accepted.
owner RegRonsibilities
The p�qject owner or the engineer or architect of record acting as the owner's agent shall fiind
special inspection services.
K. Engineer or ArCbltect-of Record Responsibilities
The engineer or architect of record shaU include special invection requirements on the plans and
specifications.
ACKNOWLEDGMENTS
I have read and agree to comply with Aw terms and conditions of this ag?*ment.
Special Inspector
GeneralContractor ID '7
City Building
�?3 t AAM t' r4� � "I
M101M
Incorporated
C 0 N S U L T I N G
E N G1 N F E R S
July 25, 2005
City of Edmonds
Building Department
121 5h Avenue North
Edmonds, WA 98020
Fax: 425-771-0221
Sub) ect: P,R,S & U Promenade Overlooks
City of Edmonds Permit No. 2004-0670
To Whom It May Concern::
PND No. 044038.03
A final *inspection of the above referenced project was completed earlier this month.
The purpose of this letter is to acknowledge that the work completed by the Port of
Edmonds for the P,R,S & U Promenade Overlooks project meets the plans and
specifications as stamped and sealed by the Engineer of Record.
Sincerely,
PNQ Incorporated eattle Office
ac,+ c� z je,2.
David Pierce, P.E.
Vice President
Cc: Bob Yeager
Port of Edmonds
RECEIVED
JUL 2 8 2005
DEVELOPMENT SERVICES CTR,
CITY OF EDMONDS
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