Backflow Test PassAfforafWe
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sac%�ow lic
PO Box 1255
Cie Elurn, WA 98922
(360) 333-2057
[?q PASS ❑ FAIL
If you have any questions about your results
or your device failed please contact us now.
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
WATER PURVEYOR Edmonds ACCOUNT #
NAME OF PREMISE Vie & Vin Wine Shop Commercial M Residential ❑
SERVICE ADDRESS 172 Sunset Ave
CITY Edmonds LIP 98020
CONTACT PERSON Brandon Mcerney owner PHONE I425r387-1659 FAX
LOCATION OF ASSEMBLY In back kitchen area behind dishwasher
DOWNSTREAM PROCESS Dishwasher
DCVA 0 RPBA ® PYB:%, ❑ OTHER
NEW INSTALL ❑ EXISTING ® REPLACEMENT ❑ REMOVED ❑ OLD SER. #
APPROVED DEVICE? YES ® NO ❑ PROPER INSTALLATION? YES ® NO ❑
MAKE OF ASSEMBLY Watts MODEL LF009QT SERIAL NO. 359210 SIZE 1/2"
INITIAL
DCVA/RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
TEST
CHECK VALVE NO.1
CHECK VALVE NO.2
AIR INLET
OPENED AT 2.2 PSID
CLOSED TIGHT ®
CLOSED TIGHT ®
OPENED AT_ 11SID
PASSED IT
#1 CHECK 8.0 PSID
LEAKED El
LEAKED ❑
DID NOT OPEN ❑
FAILED ❑
PSID
PSID
AIR GAP OK? X
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
NEW
PARTS
❑ ❑
❑ ❑
❑ ❑
HELD AT PSID
A:ND
❑ ❑
❑ ❑
❑ ❑
LEAKED ❑
REPAIRS
❑ ❑
❑ ❑ —
❑ ❑
CLEANED ❑
❑ ❑
❑ ❑
❑ ❑
REPA RED ❑
TEST :�I•-I ER
REPAIRS
CLOSED TIGHT ❑
CLOSED TIGHT ❑
OPENED AT PSID
AIR INLET PSID
PSID
PSID
#1 CHECK PSID
PASSED ❑
CHK VALVE PSID
FAILED ❑
AIR GAP INSPECTION: Required nuninn in air gap separation provided? Yes ❑ No ❑ Detector Meter Reading
LEFT SERVICE AS FOUND: ISO VALVE Open ® Closed ❑ SOV 1 Open ® Closed ❑ SOV 2 Open ® Closed O
REMARKS: LINE PRESSURE 74 PSI
METER NUMBER CONFINED SPACE? No
TESTERS SIGNATURE:
TESTERS NAME PRINTED: Taro Smithson
REPAIRED BY:
CERT. NO. B7464 DATE 03-23-24
_ TESTERS PHONE # ( 360)333-2057
DATE
FINAL TEST BY: CERT. NO. DATE
CALIBRATION DATE 12-04-2023 GAUGE # 04192518 MODEL 845 SERVICE RESTORED? YES ® NO ❑
I rertify that this report Is arch/ate, and I hare used RAC 246-290-490 appro►vd test methods and test equipment.