RPBA initial certification.pdfAffordable Washington Backflow
1701 1 st St.
Snohomish, WA 98290
(360) 333-2057
(425) 892-4808
ACCOUNT#
NAME OF PREMISE ` l j Commercia Residential ❑
SERVICE ADDRESS (%� CITY �� ZIP 9 &-0'2 C
CONTACT PERSON A t V0' Q PHONE ( ) FAX ( )
LOCATION OF ASSEMBLY / i S �'"I Uj A ,
DOWNSTREAM PROCESS 0j S VI ,' DCVA ❑ RPBA PVBA ❑ OTHER
NEW INSTALL EXISTING ❑ REPLACEMENT ❑ OLD SER. # PROPER INSTALLATION? YES NO ❑
MAKE OF ASSEMBLY16 MODEL SERIAL NO. SIZE
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Reading
REMARKS:
TESTERS SIGNA'
LINE PRESSURE(dC PSI
APPROVED DEVICE? YES I V NO ❑ CONFINED SPA E?
CERT. NO. B5134 DATE
TESTERS NAME PRINTED: David T. Foy TESTERS PHONE # ( 360 ) 333-2057
REPAIRED BY:
FINAL TEST BY:
DATE
CERT. NO. DATE
CALIBRATION DATE 12 /21 /11 GAUGE # 04090046 MODEL Midwest 845-5 SERVICE RESTORED? YE NO ❑
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
INITIAL
CHECK VALVE NO.1
CHECK VALVE NO.2
AIR INLET
TEST
OPENED AT jr PSID
OPENED AT PSID
LEAKED ❑
LEAKED ❑
#1 CHEC r PSID
PASSEDW
DID NOT OPEN ❑
FAILED 13
PSID
PSID
AIR GAP OK? _X
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
NEW
❑ ❑
❑ ❑
❑ ❑
HELD AT PSID
PARTS
❑ ❑
❑ ❑
❑ ❑
LEAKED ❑
AND
REPAIRS
11 ❑
❑ ®
❑ ❑
CLEANED ❑
❑ ❑
❑ ❑
❑ ❑
REPAIRED ❑
TEST AFTER
REPAIRS
LEAKED ❑
LEAKED ❑
OPENED AT PSID
AIR INLET PSID
PASSED ❑
PSID
PSID
#1 CHECK PSID
CHK VALVE PSID
FAILED ❑
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes ❑ No ❑ Detector Meter Reading
REMARKS:
TESTERS SIGNA'
LINE PRESSURE(dC PSI
APPROVED DEVICE? YES I V NO ❑ CONFINED SPA E?
CERT. NO. B5134 DATE
TESTERS NAME PRINTED: David T. Foy TESTERS PHONE # ( 360 ) 333-2057
REPAIRED BY:
FINAL TEST BY:
DATE
CERT. NO. DATE
CALIBRATION DATE 12 /21 /11 GAUGE # 04090046 MODEL Midwest 845-5 SERVICE RESTORED? YE NO ❑
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.