BLD2023-0623+Backflow Test+2.13.2024_1.19.47_PM+4057211A. R. Brown Backflow Testing
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PO Box 931
Backflow Preventer Inspection
A. R. Brown BQkkfl>
ow Testing.
Lynnwood, WA98046
2068186549
and Field Test Report arbrownbft@gmail.com
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PWS ID j Water System Name Edmonds, Washington File #
Facility Name Residential Property ❑ Non -Residential ❑ Residential
Service Address 19515 94th PI. W City Edmonds Zip 98026
Contact Person
Phone
Email
Hazard Type (if known) rrigation
® DCVA ❑ RPBA ❑ PVBA ❑ AG ❑Other
Preventer Physical Location Behind water meter
® New ❑ Existing ❑ Replacement: Old Ser. #
Confined Space Yes ❑ No IN
Assembly Make Febco +Mroper
odel 850
Serial # HG75067
Size 1" "
USC-Approved Yes ®No
Install Yes ®No El
Proper Orientation Yes ®No ❑
Initial Test
DCVA
RPBA
PVBA/SVBA
Check Valve 1
Relief Valve
Air Inlet Valve
Passed ®
Leaked ❑ 25 psid
Opened_ psid/ Not Open❑
Opened at _ psid
Failed ❑
Check Valve 2
Check Valve 2
Did Not Open El
Opened Fully Yes ❑ No❑
Leaked - 2.4 psid
Closed Tight ❑ Leaked ❑
Check Valve
Check Valve 1 psid
_psid
_
Leaked L
Cleaned ❑ Repaired ❑
Approved Air Gap Yes❑ No❑
Cleaning,
Cleaned ❑ Repaired ❑
Cleaned ❑ Repaired ❑
Repairs,
El Disc
❑O-Ring(s)
El Disc
❑O-Ring(s)
❑Air Inlet Disc
El Float
&
❑Spring
❑Module
❑Spring
❑Module
❑Air Inlet Spring
El Diaphragm
Parts
❑Guide
❑Rubber Kit
El Diaphragm
❑Rubber Kit/Guide
❑Check Disc
El Rubber Kit
❑Seat
❑
El Seat
❑
El Check Spring
❑
Final Test
Check Valve 1
Relief Valve
Air Inlet Valve
Leaked psid
Opened at psid
Opened at psid
Passed ❑
_
_
Check Valve 2
Check Valve 2 Closed Tight ❑
Opened Fully Yes ❑ No❑
Failed ❑
Leaked :--] _ psid
Check Valve 1 psid
Check Valve psid
Air Gap Inspection Pass ❑ Fail ❑
Supply Pipe Diameter
Air Gap Separation "
Line Pressure 55 psi
Detector Meter Gals❑ CuFt ❑
Service Restored Yes ❑ No®
Remarks*
Test Kit Make & Model Mid -West 835-5
Serial #06100400
Ver./Cal Date** 01-29-2024
B this
Y
1. 1 personally inspected and field-tested the backflow assembly using field test procedures meeting
1A►At- Inc 1]nn Ann --A 4. 4 . ..a ... ..a:...- IA/AY' Inc Inn nOA. . I
signature, I --.... _ .., _.... ..... ............ .......r...,,......,,,,....y
certify: I gap or AVB.
G. I IV IIIIVIIIIQLIVII 1 1111J 15WVIL IJ uC, l.Vlll IGLU, Qllu CIUUUlCILU.
BAT Signature (initial test
Cert. # 6113
Date/Time02-08-2408:35
BAT Name (print)
BAT Phone # 2068186549
Repaired By
I Date/Time
BAT Signature (after repair)
BAT Name (print)
BAT Company Name A. R. Brown Backflow Testinq
Cert. # Date/Time
BAT Phone #
Address PO Box 931 Lynnwood, WA 98046
"Note unapproved backflow preventer, missing/defective components, repairs made, or conditions that may adversely affect
assembly.
"The date of the most recent field test kit verification of accuracy or calibration whichever is most recent.