field test reportBACKFLOW PREVENTER INSPECTION & FIELD TEST REPORT
ACCOUNT # 188
ALWAYS TESTING INC.
6501 227th St. SW, MOUNTLAKE TERRACE, WA 98043
(206) 718-8378 (425) 672-4345
Facility Name Edway Tap House
Commercial Residential ❑
SERVICE ADDRESS 22805 -100th Ave W
CITY
Edmonds ZIP 98020
CONTACTPERSON V' ,�U
/ aa
9- �fiC]
Phone/ Email:
Hazard Type (if known) Dishwasher
DCVA ❑
RPBA PVBA ❑ AG ❑ OTHER
❑
Preventer Physical Location its 1)15AWns,, e-,,—
NEW INSTAL XISTING REPLACEMENT
❑ OLD SER #
Confined Space YES ❑
ASSEMBLY MAKE Watts
MODEL LF 00-7
SERIAL NO. 3''9,2`1-3 SIZE 1 ��
USC-Approved YES ® NO ❑
Proper Install YES X❑
NO ❑ Proper Orientation YES E]NO❑
DCVA
RPBA
PVBA/SVBA
INITIAL
TEST
CHECK VALVE NO. 1
Relief Valve
Opened
psid/
Not Open ❑
Air Inlet Valve
Leaked ❑ psid
OPENED A" PSID
PASSED
x
CHECK VALVE NO. 2
Check Valve 2
Closed Tight 19
Leaked
DID NOT OPEN ❑
Opened Fully Yes ❑ No
FAILED
Leaked ❑ psid
Check Valve 1
F3 psid
Check Valve psid
Approved Air Gap
YES :g
NO ❑
Leaked ❑
CLEANEDL_PEPMCED=
CLEANED 0 REPLACEDO
CLEANED = REPIACED
❑Disc
❑O-Rin s
❑ Disc
❑ O-Rin
s
❑ Air Inlet Disc
Float
CLEANING
S rin
Module
LJ Spring
Module
Air Inlet Spring
Diaphragm
REPAIRS
EDGuide
LJRubber Kit
Diaphragm
LJ Rubber Kit/Guide
Check Disc
Rubber Kit
& PARTS
eat
E
Seat
7 Check spring
FINAL TEST
CHECK VALVE NO. 1
RELIEF VALVE
AIR INLET VALVE psid
Leaked ❑ psid
Opened at
psid
Opened at psid
PASSED ❑
CHECK VALVE NO. 2
Check Valve 2
Opened Fully Yes ❑Jo ❑
FAILED ❑
Closed Tight
❑
Leaked ❑ psid
Check Valve 1
Check Valve psid
psid
Air Gap Inspection: Pass ❑Fail ❑
Supply Pipe Diameter
of
jAIr Gap Separation "
REMARKS:
Line Pressure PSI
Detector Meter Reading
By this 1. 1 personally inspected and field-tested the backflow assembly using field test procedures meeting WAC
signature, 1 246-290-490 and test equip ent meeting WAC 246-292-034; or I personally inspected the air gap or AVB.
certify: 2. The information in this r rt is e, mplete, and accurate.
TESTERS SIGNATURE CERT. NO. 3822 DATE 3/4/2024
TESTERS NAME PRINTED Darin Schnee TESTERS PHONE # ( 206 ) 718 - 8378
REPAIRED BY DATE
BAT Signature (after
CALIBRATION DATE
CERT. NO.
DATE
07/11/2023 GAUGE # 0409 1223 MODEL 835 SERVICE RESTORED? YES ❑ NO 0