Annual BF 2024NOBTAWEST FIRE SYSTEMS
SPBIHKIER & Hill AtAHN
Saving Lives, Protecting Property
22645 83rd Ave S, BIg D, Kent, WA 98032
206-772-7502 (phone)* 206-772-7504 (fax)
License No.: NORTHFS928CR
CERTIFICATION GIVEN
RED ❑ W YELLOW ❑ 11 WHITE 0
Backflow Prevention Assembly
Confidence Test Report
Please forward this report to the local fire
prevention authority in your area.
Date of Inspection:
03/11/2024 02:00pm PDT Water Restored: Yes ❑� No ❑ Authorized Tester:
Northwest Fire Systems
Facility Name:
Private residence Commercial:
❑
Residential: ❑�
Service Address:
332 Sunset Ave N City: Edmonds
Zip:
98020
Contact Name:
Phone:
Fax:
Assembly Location:
Bottom floor riser/electrical room by laundry machines Assembly/Hazard ID #:
Hazard Type: Sprinkler DCVA ® RPBA ❑ PVBA ❑ AG ❑
Other:
New Install: Z
Existing: ❑ Replacement: ❑ Old SN:
Proper Install? Yes ® No ❑
Make of Assembly:
Ames Model: 200b Serial #: 61263
Size: 2inch
DCVA/ RPBA
DCVA/ RPBA
RPBA
PVBA/ SVBA
INITIAL TEST
AIR INLET
CHECK VALVE #1
CHECK VALVE #2
Opened at PSID
Opened at PSID
PASSED
Leaked ❑
Leaked ❑
#1 Check PSID
Check Valve PSID
FAILED ❑
9 9 PSID
9 PSID
Did not Open ❑
Air Gap OK
Clean Replace Part
Clean Replace Part
Clean Replace Part
Check Valve
NEW PARTS
❑ ❑
❑ ❑
❑ ❑
Held at PSID
AND
❑ ❑
❑ ❑
❑ ❑
Leaked ❑
❑ ❑
❑ ❑
❑ ❑
Cleaned ❑
REPAIRS
❑ ❑
❑ ❑
❑ ❑
Repaired ❑
TEST AFTER REPAIRS
CHECK VALVE #1
CHECK VALVE #2
Opened at PSID
Opened at PSID
PASSED ❑
Leaked ❑
Leaked ❑
#1 Check PSID
Check Valve PSID
FAILED ❑
PSID
PSID
Air Gap OK
Air Gap Inspection:
Remarks:
Testers Signature:
Meter Reading: Separation: Air Gap: Pass ❑ Fail ❑
Line Pressure: 115 PSI
Confined Space: Yes ❑ No ❑�
I Cert. No. R6724 Date: 14/11194
Testers Name Prnted. Aller. harrnw Office Phone: 206-772-7502
Make / Model / Gauge # MirlwPct/R45/n51 PmR:3
Final Test
Testers Signature:
Testers Name Printed:
Make / Model / Gauge #
Cert. No.
Calibration Date: 4/9:1
Date:
Calibration Date:
I certify that this report is accurate and I have used WAC 264-290-490 approved test methods and test equipment.