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SMCE Medivator RPBP test - Oct 31 2022 - 8-55 AM (2)SITEL"e MacDonald -Miller �y FACILITY SOLUTIONS Reset Form NEW ❑ EXISTING ❑ REPLACEMENT (OLD SER #) ASSEMB Y MANUFACTURER �t5S" MODEL ER Wvu.�011 SIZE FACILITY ID FACI NAME F CILTTYf� NTACT NAME P NE EMAIL • u>40 d td — e�as 'f S-.1 o ` dD,D�t�,tJ 9eo SERVICE ADDRESS 2/ Ga 7 c� ,,, J.tr as ZIP PREV�ITER PHYSICAL LQCATT A / 7 �� I/G'0�V 02 /Y r/ �P s HAZARD TYPE ! DOWNSTREAM PROCESS �l�a , �.� ;rVR 7` T �1 ❑ DCVA RPBA ❑ PVBA ❑ AG WATER SERVICE RESTORED RECORD DETECTOR METER READING -WHEN APPLICABLE ❑ other Yes D No /Vi4 ❑Gal ❑ CuFt USC APPROVED Yes ❑ No PROPER INSTALLATION Yes PROPER ORIENTATION CONFINED SPACE LINE PRESSURE ❑ No Yes ❑ No ❑Yes No 85 psi Initial Test DCVA RPBA PVBAISVBA Check Valve 1 Relief Valve Air Inlet Valve Passed ❑ Leaked psid Opened 3 • Z psid/ ❑ Not Open p Opened p psid ❑Not Open ❑ Failed Check Valve 2 Check Valve 2 Opened Fully ❑ Yes ❑ No ❑ Leaked psid VCIosed Tight ❑ Leaked Check Valve psid Check Valve 1 7. ,7 psid ❑ Leaked Approved Air Gap Yes ❑ No Cleaning, ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired Repairs, 81 ❑Disc ❑O-Ring(s) ❑Disc ❑O-Ring(s) ❑Air Inlet Disc ❑Float ❑Spring []Module ❑Spring ❑Module ❑Air Inlet Spring ❑Diaphragm Parts ❑Guide ❑Rubber Kit ❑Diaphragm ❑Rubber Kit/Guide ❑Check Disc ❑Rubber Kit ❑Seat ❑ Meat ❑ ❑Check Spring ❑ Final Test Check Valve 1 Relief Valve Air Inlet Valve ❑ Passed ❑ Leaked psid Opened psid/ Opened psid ❑ Failed Check Valve 2 Check Valve 2 ❑ Closed Tight 9 Opened Fully ❑ Yes ❑ No ❑ Leaked psid Check Valve 1 psid Check Valve psid AIR GAP INSPECTION ❑ Passed ❑ Failed SUPPLY PIPE DIAMETER AIR GAP SEPARATION LEFT SERVICE AS FOUND I Isolation Valve: ❑ Open ❑ Closed SOV#1: ❑ Open ❑ Closed SOV*2: ❑ Open ❑ Closed REMARKS' .221 D 2s- DD'1S` �C By this 1.1 personally inspected and field-tested the backflow assembly using field test procedures meeting signature, WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air I certify: gap or "B. 2. The information in this report is true, complete, and accurate. INFrJAL TEST BY (PRINT AT r!SyR NAME) z1AdM BAT COMPANJ NAME BAT PHONE BAT CERT X: DATE TESTED CZ7- ?. "46 �� 20457011,0f2 6 �711 IV-1(P'LZ rBAT9 NAT RE TEST KIT MAKE & MODEL SER X chi VER/CAL DATE" z zZ -d -iS REPAIRED BY DATE dd /t- AFTER REPAIR TESTED BY(PRINT NAME) BAT COMPANY NAME W114 BAT PHONE BAT CERT X: DATE TESTED ,#"+ At,+ *,d- *Vl* BAT SIGNATURE '�'� TEST KIT MAKE 3 MODEL "-4- SERIAL X A14 VERICAL DATE"" 1 P /a - 'Note unapproved oacRrrow preventer, missmgiaerecnve components, repairs made, or conditions that may adversely affect assembly. "The date of the most recent field test kit veriflcatlon of accuracy or calibration whichever Is most recent MacDonald=Miller FACILITY SOLUTIONS',R' Reset Form NEW ❑ EXISTING ❑ REPLACEMENT (OLD SER #) ASSEMBLY MANUFACTURER ��'!75 MODEL SERIAL NUMBER J Z `t 9 8 % S9ZE - fez ti* FAC2LITY ID e�J FA NAME � — F LrTY ONTACT NAME PHONE EMAIL �Q �o �6W ,� astiN ZS �?2B 900L SERVICE AD ESS Z/ D/ 76 uJ c2Lv j"0AJAS ZIP PREVEER PHYSICAL LOCATION HAZARD TYPE ! =REAM PROCESS ❑ DCVA APBA ❑ PVBA ❑ AG WATER SERVICE RESTORED RECORD DETECTOR METER READING -- WHEN APPLICABLE ❑ Other Yes ❑ Now ❑ Gal ElCuFt USC APPROVED Yes ❑ No PROPER INSTALLATION PROPER ORIENTATION CONFINED SPACE LINE PRESSURE Yes ❑ No Yes ❑ No ❑ Yes A No 75 psi Initial Test DCVA RPBA PVBA/SVBA Check Valve 1 Relief Valve Air Inlet Valve Passed ❑ Leaked psid Opened 1• Lpsid/ ❑ Not Open Opened psid ❑ Not Open ❑ Failed Check Valve 2 Check Valve 2 Opened Fully ❑ Yes ❑ No ❑ Leaked psid XClosed Tight ❑ Leaked Check Valve psid Check Valve 1 g . O psid ❑ Leaked Approved Air Gap kYes ❑ No Cleaning, ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired ❑Disc ❑O-Ring(s) ❑Disc ❑O-Ring(s) ❑Air Inlet Disc []FloatRepairs, ❑Spring ❑Module ❑Spring ❑Module ❑Air Inlet Spring ❑Diaphragm Parts ❑Guide ❑Rubber Kit ❑Diaphragm ❑Rubber Kit/Guide ❑Check Disc ❑Rubber Kit ❑Seat ❑ ❑Seat ❑ ❑Check Spring ❑ Final Test Check Valve 1 Relief Valve Air Inlet Valve ❑ Passed ❑ Leaked psid Opened psid/ Opened psid ❑ Failed Check Valve 2 Check Valve 2 ❑ Closed Tight 9 Opened Fully El Yes ❑ No ❑ Leaked psid Check Valve 1 psid Check Valve psid AIR GAP INSPECTION ❑ Passed ❑ Failed SUPPLY PIPE DIAMETER AIR GAP SEPARATION " LEFT SERVICE AS FOUND Isolation Valve: ❑ Open ❑ Closed SOV#1: ❑ Open ❑ Closed SOV#2: O Open ❑ Closed REMARKS' ZZ DD `-5- 772-1 - 2ff l ,a this 1.1 personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air signature, sgnature, gap or AVB. I certify: 2. The information in this report is true, complete, and accurate. IN TEST BY (PRIN BAT•TI�ER NAME) og047- W - l��cdrr, BAT COMPA NAME /11.c� �.yr r-�.Q-!'YID BAT PHONE D 51d yv�i L BAT CERT t► �g /� DATE TESTED rD-L�_ tz B GNATURE TEST KIT MAKE & MODEL SERIAL VERICAL DATE" REPAIRED BY A DATE , r AFTER REPAIR TESTED BY(PRINT NAME) BAT COMPANY NAME BAT PHONE BAT CERT *: DATE TESTED /lJd [BAT SIGNATURE TEST KIT MAKE & MODEL ,! SERULL it VERlCAL DATE -nvav ......pr.. �_-_ ���........ .......o...o. nnaaunwUtpra..uw .......,.....a..w, --I- ...a..v, ... ..vuuauuu.uv,.a �„d,.way aaversery atrect assembly. —The date of the most recent field test kit verification of accuracy or calibration IMhichever Is most recent. MacDonaldmMmiler �,, Reset Form FACILITY( SOLUTIONSS, EW ❑EXISTING ❑ REPLACEMENT (OLD SER #) ASSEMNA�C�R MODSERIAL ��� gl ID FAC']�!'� ! Q J FACLAMFACITY CCMA1LE NM SERVEAr;zIP C;tz A✓lv.dd S PREVEN ER PHYSICAL LOCATION � o / � L oone oP` 4f HAZARD E I DFWNSTREAM PROCESS a 7a,,?, /-407- ,vh ❑ DCVA XRPBA ❑ PVBA ❑ AG WATER SERVICE RESTORED RECORD DETECTOR METER READING - WHEN APPLICABLE ❑ Other Yes ❑ No A -rl* ❑ Gal ❑ CuFt USC APPROVED Yes ❑ No PROPER INSTALLATION PROPER ORIENTATION CONFINED SPACE LINE PRESSURE Yes ❑ No X Yes ❑ No ❑ Yes No 85' psi Initial Test DCVA RPBA PVBA/SVBA Check Valve 1 Relief Valve Air Inlet Valve ,Passed ❑ Leaked psid Opened 3, y psid/ ❑ Not Open Opened psid ❑ Not Open ❑ Failed Check Valve 2 Check Valve 2 Opened Fully ElYes ElNo ❑ Leaked psid Closed Tight ❑ Leaked Check Valve psid Check Valve 1 81• 2— psid ❑ Leaked Approved Air Gap es ❑ No Cleaning, ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired Repairs, $ ❑Disc ❑O-Ring(s) ❑Disc ❑O-Ring(s) ❑Air Inlet Disc ❑Float ❑Spring ❑Module ❑Spring ❑Module ❑Air Inlet Spring ❑Diaphragm Parts ❑Guide ❑Rubber Kit ❑Diaphragm ❑Rubber Kit/Guide ❑Check Disc ❑Rubber Kit ❑Seat ❑ ❑Seat ❑ ❑Check Spring ❑ Final Test Check Valve 1 Relief Valve Air Inlet Valve ❑ Passed ❑ Leaked psid Opened psid/ Opened psid ❑ Failed Check Valve 2 Check Valve 2 ❑ Closed Tight g Opened Fully ❑ Yes ❑ No ❑ Leaked psid Check Valve 1 psid Check Valve psid AIR GAP INSPECTION ❑ Passed ❑ Failed SUPPLY PIPE DIAMETER AIR GAP SEPARATION " LEFT SERVICE AS FOUND Isolation Valve: ❑Open ❑Closed SOV#1: ❑ Open ❑ Closed SOV#2: ❑ Open ❑ Closed REMARKS' By this 1.1 personally inspected and field-tested the backflow assembly using field test procedures meeting signature, WAC 246-290-490 and test equipment meeting WAC 246-292-034; or i personally inspected the air I certify: gap or AVB. 2. The information in this report is true, complete, and accurate. IN TEST BY (PRIN AT TE ER NAME) BAT COMPANgqNAME adY�i- BAT PHONE BAT CERT ► 1 DATE TESTED BiLRT�jB, crrJ�i4 /Ylat W&fit o S/oL/,VfiL '`f7/r 40-2f-2Z TEST! ; Wes -r LP J� f�'/�(� i SERIAL '2 R,0/O3 !,//J (/ VER/CA �DA� S Z Z_ i REPAIRED BY DATE AFTER REPAIR TESTED BY(PRINT NAME) E BAT COMPANY NAM/ BATPHONE ,,' BAT CERT0: DATE TESTED A/ I % 4 N A1.4 N,4 BAT SIGNATURE TEST KIT MAKE & MODEL SERIAL # VERICAL DATE - -Note unapprovea oacxTlow preventer, missingvcreteetive components, repairs mace, or conmations that may adversely affect assembly. --The date of the most recent field test kit verilicatlon of accuracy or calibration whichever Is most recent MacDonaldmMiller FACILITY SOLUTIONSc, Reset Form NEW ❑ EXISTING ❑ REPLACEMENT (OLD SER #) ASSEMBLY MANUFACTURER MODEL SERIAL NUMBER SQE FACILITY ID Gti��rS FACIL AME FACILITY CONTACT NAME PHONE EMAIL �0s - c.?,a cd T ,.� •ibs • ,v �l Zs z z0 4*0 0 SERVICE ADDRESS 2 i Go l 7G AA vQ cc� ..�.v d -f SIP PRE TER PHYSICALK/7 fLOC�ATfON D / 7 / [' J� .PSI G.Grr HAZARD TYPE I DOWNSTREAM PROCESS Af t 444 TD k L.a ❑ DCVA )(RPBA ❑ PVBA ❑ AG WATER SERVICE RESTORED RECORD DETECTOR METER READING - WHEN APPLICABLE ❑ Other X Yes ❑ No AJA ❑ Gal ❑ CuFt USC APPROVED Yes ❑ No PROPER INSTALLATION 19 Yes ❑ No PROPER ORIENTATION Yes ❑ No CONFINED SPACE ❑ Yes Sd No LINE PRESSURE I psi Initial Test DCVA RPBA PVBA/SVBA Check Valve 1 Relief Valve Air Inlet Valve Passed ❑ Leaked psid Opened .3, Z psid/ ❑ Not Open Opened psid ❑ Not Open ❑ Failed Check Valve 2 Check Valve 2 Opened Fully ❑ Yes ❑ No ❑ Leaked psid XClosed Tight ❑ Leaked Check Valve psid Check Valve 1 &y• Z psid ❑ Leaked Approved Air Gap JXYes ❑ No Cleaning, ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired ❑ Cleaned ❑ Repaired 8� ❑Disc ❑O-Ring(s) ❑Disc ❑O-Ring(s) ❑Air inlet Disc []FloatRepairs, ❑Spring ❑Module ❑Spring ❑Module ❑Air Inlet Spring ❑Diaphragm Parts ❑Guide ❑Rubber Kit ❑Diaphragm ❑Rubber Kit/Guide ❑Check Disc ❑Rubber Kit ❑Seat 10 ❑Seat ❑ ❑Check Spring ❑ Final Test Check Valve 1 Relief Valve Air Inlet Valve ❑ Passed ❑ Leaked psid Opened psid/ Opened psid ❑ Failed Check Valve 2 Check Valve 2 ❑ Closed Tight 9 Opened Fully ❑ Yes ❑ No ❑ Leaked psid Check Valve psid Check Valve psid AIR GAP INSPECTION ❑ Passed ❑ Failed SUPPLY PIPE DIAMETER AIR GAP SEPARATION LEFT SERVICE AS FOUND Isolation Valve: ❑Open ❑Closed SOV#1: ❑ Open ❑ Closed SOV#2: ❑ Open ❑ Closed REMARKS' DD�� �ZZ/ Y7,5� B this y 1.1 personally inspected and field-tested the backflow assembly using field test procedures meeting signature, WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air I certify: gap or AVB. 2. The information in this report is true, complete, and accurate. INR EST BY (PRINT AT T�EsyER NAME) o DE27 � /Yii'op",.j BAT COMPn�+Y NAME Alpe JdXA,�- ,�G�, AT PHONE f�TP -41012- BAT CE�'��?? B T7i/ DATE TESTED /0-Z F- Z Z BAT N TURE �.� Jf�l/.c TEST KIT MAKE 8 MODEL 83S SERUU 4 03 Z ov�o3 VERICAL DATE" M.��✓�.sr REPAIRED BY A14 DATE Al w AFTER REPAIR TESTED RINT NAME) BAT COMPANY NAME, /�, ' BATPHONE BAT CER /i DATE TESTED BAT SIGNATURE XIA, TEST KITMAKE 5; ODEL SERIAL / VERICAL DAT /v Af. -Note unapprovea Dacxnow prevenrer, missing/defective components, repairs made, or condition mat may adversely arrect assembly. **The date of the most recent field test kit verification of accuracy or calibration whichever Is most recent.