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16111 75TH PL W (2).PDF16111 75TH PL W STREETADDRESS FILE CITY OF EDMONDS BARBARA FAHEY MAYOR 7110-210TH ST.S.W. - EDMONDS, WA 98026 - (206) 771-0235 - FAX (206) 744-6057 COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION cSt. 189v July 22,1997 CERTIFIED FINAL NOTICE ATTN: JACK EVANS MEADOWDALE MARINE 16111 75th PL. W. . Edmonds, WA 98026 Subject: Backflow Prevention Assembly Testing - Account #604150 On June 2, 1997, you were notified by letter that your backflow, prevention assembly was due for annual testing. On July 1, 1997, the second notice was sent which stated that you had 15 days to take care of this matter. Failure to comply, according to the City of Edmonds Ordinance Chapter 7.20 and Washington State codes WAC 246-290-490, water service to your premises will be discontinued if test results are not sent to me within 20 days from the date of this letter. Should you have any questions or concerns, please contact me at 771-0235, extension 644. Sincerely, Linda McMurphy Water Quality Control wordaWwater\final • Incorporated August 11, 1890 • Sister Cities International — Hekinan, Japan CITY OF EDMONDS BARBARA FAHEY MAYOR 7110-210TH ST.S.W. • EDMONDS, WA 98026 • (206) 771.0235 • FAX (206) 744-6057 COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION Est. 189�) June 2, 1997 Meadowdale Marine Ron Hansen 161 1 1 76th PI. Edmonds, WA 98026 Account #604150 SUBJECT: BACKFLOW PREVENTION ASSEMBLY TESTING Our records show the backflow prevention assembly(s) in your water supply system is due for annual testing as required by state code WAC 246-290-490. Please have the testing performed by a person holding a certificate of competency as a Backflow Assembly Tester, issued by the state department of social and health services (telephone 1-800-525-2536). If your assembly(s) fails its test, please have the necessary repairs made. Upon completion of a satisfactory test, have the certified tester fill out the enclosed test and maintenance report (see attached form) and return it to this office within thirty days from receipt of this letter. Additional information relative to this matter may be obtained by contacting me at 771- 0235, extension 644 between 7:30 AM and 4:30 PM Monday thru Friday. Sincerely, Linda McMurphy Water Quality Control Specialist Enclosures * Incorporated August 11, 1890 0 Sister Cities International — Hekinan, Japan CITY OF EDMONDS 7110-210TH ST.S.W. • EDMONDS, WA 98026 • (206) 771-0235 • FAX (206) 744-6057 COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION FS $90 July 1, 1997 Meadowdale Marine Ron Hansen 161 1 1 76th PI. Edmonds, WA 98026 Account #604150 SECOND NOTICES C(0[py 13ARBARA FAHEY MAYOR A previous letter was mailed to you requiring testing of existing backflow prevention assembly(s) installed in your water system. Our records show that to date, the necessary inspection test report has not been received. In order that such assemblies continue to operate properly in protecting water quality, they must be tested and serviced .when required. Accordingly, you are required to have your assembly(s) tested within 30 days from the date of the first letter. The tester must complete the enclosed inspection test report(s) and return them to our office. _ If the required test report(s) are not received within 15 days of this letter, water service to the premises may be discontinued as provided in the city of Edmonds ordinance chapter 7.20 and WAC 246-290-490. Additional information relative to this matter may be obtained by contacting me at 771-0235, extension 644. Please disregard this notice if you have already submitted your test result form(s). Sincerely, Linda McMurphy Water Quality Control specialist Enclosures BKFL2ND.WPS • Incorporated August 11, 1890 • Sister Cities International — Hekinan, Japan STREET ADDRESS FILE CITY OF EDMONDS BARBARA FAHEY a MAYOR 7110-210TH ST.S.W. • EDMONDS, WA 98026 • (206) 771-0235 • FAX (206) 744-6057 -- COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION �St. 18c�0 July 22,1997 CERTIFIED FINAL NOTICE ATTN: PROPERTY OWNER MEADOWDALE MARINE 16111 75th PL. W. Edmonds, WA 98026 Subject: Backfiow Prevention Assembly Testing - Account #604150 On June 2, 1997, the Meadowdale Marina was notified by letter that the backflow prevention assemblies were due for annual testing. On July 1, 1997, the second notice was sent which stated that the marina had 15 days to take care of this matter. Failure to comply, according to the City of Edmonds Ordinance Chapter 7.20 and Washington State codes WAC 246-290- 490, water service to the above address will be discontinued if test results are not sent to me within 20 days from the date of this letter. Should you have any questions or concerns, please contact me at 771-0235, extension 644. Sincerely, Linda McMurphy Water Quality Control wordata\water\final r • Incorporated August 11, 1890 Sister Cities International — Hekinan, Japan CITY OF EDMONDS BARBARA FAHEY MAYOR 7110-210TH ST.S.W. • EDMONDS, WA 98026 • (206) 771-0235 • FAX (206) 744-6057 COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION rSt. 189v June 2, 1997 Meadowdale Marine Ron Hansen 16111 76th PI. Edmonds, WA 98026 Account #604150 SUBJECT: BACKFLOW PREVENTION ASSEMBLY TESTING Our records show the backflow prevention assembly(s) in your water supply system is due for annual testing as required by state code WAC 246-290-490. Please have the testing performed by a person holding a certificate of competency as a Backflow Assembly Tester, issued by the state department of social and health services (telephone 1-800-525-2536). If your assembly(s) fails its test, please have the necessary repairs made. Upon completion of a satisfactory test, have the certified tester fill out the enclosed test and maintenance report (see attached form) and return it to this office within thirty days from receipt of this letter. Additional information relative to this matter may be obtained by contacting me at 771- 0235, extension 644 between 7:30 AM and 4:30 PM Monday thru Friday. Sincerely, Linda McMurphy Water Quality Control Specialist Enclosures • Incorporated August 11, 1890 • Sister Cities International — Hekinan, Japan COPY CITY OF EDMONDS BARBARAFAHEY MAYOR 7110-210TH ST.S.W. • EDMONDS, WA 98026 • (206) 771-0235 • FAX (206) 744-6057 COMMUNITY SERVICES DEPARTMENT - PUBLIC WORKS DIVISION L`St 1S9v July 1, 1997 Meadowdale Marine Ron Hansen 161 1 1 76th PI. Edmonds, WA 98026 Account #604750 SECOND NOTICES A previous letter was mailed to you requiring testing of existing backflow prevention assembly(s) installed in your water system. Our' records show that to date, the necessary inspection test report has not been received. In order that such assemblies continue to operate properly in protecting water quality, they must be tested and serviced when required. Accordingly, you are required to have your assembly(s) tested within 30 days from the date of the first letter. The tester must complete the enclosed inspection test report(s) and return them to our office. If,the required test report(s) are not received within 15 days of this letter, water service to the premises may be discontinued as provided in the city of Edmonds ordinance chapter 7.20 and WAC 246-290-490. Additional information relative to this matter may be obtained by contacting me at 771-0235, extension 644. Please disregard this notice if you have already submitted your test result form(s). Sincerely, Linda McMurphy Water Quality Control specialist Enclosures BKFL2ND.WPS • Incorporated August 11, 1890 • Sister Cities International — Hekinan, Japan STREET FILE CITY OF EDMONDS -- PUQLIC WORKS DEPARTMENT BACKFLOW DEVICE TEST REPORT NAME OF PREMISES AUG 13 Ijyu PUBLIC 6'd01`?f(S SERVICE ADDRESS /�� � `� ' �4fv. LOCATION OF DEVICE _X �' � � " � .- �j� /11-- oc/vr !DEVICE: re4C. f Manufacturer Mo el STzef Serial No. LINE PRESSURE AT TIME OF TEST ® LBS. PRESSURE DROP ACROSS FIRST CHECK VALVE LBS. _ CHECK VALVE NO. 1 CHECK VALVE NO. 2 DIFFERENTIAL PRESSURE RELIEF VALVE INITIAL 1. LEAKED ❑ 1. LEAKED ❑ 1. OPENED AT LBS. TEST 2 CLOSED TIGHT 2. CLOSED TIGHT REDUCED PRESSURE 2. DID NOT OPEN O CLEANED ❑ CLEANED ❑ CLEANED p REPLACED: REPLACED: REPLACED: DISC ------------- ❑ DISC ---------=--- ❑ DISC.UPPER---------------------- ❑ R SPRING ----------- ❑ SPRING ----------- ❑ DISC. LOWER ------------------ ---- 0 E GUIDE ------------ ❑ GUIDE ------------ ❑ SPRING -------------------------- ❑ p PIN RETAINER ----- ❑ PIN RETAINER----- ❑ DIAPHRAGM, LARGE A HINGE PIN -------- ❑ HINGE.PIN-------- ❑ UPPER------------------------- ❑ I SEAT ------------= ❑ SEAT------------- ❑ LOWER------------------------- 0 R DIAPHRAGM1-------- ❑ DIAPHRAGM-=------ ❑ DIAPHRAGM, SMALL S OTHER, DESCRIBE -- ❑ OTHER, DESCRIBE -- ❑ UPPER------------------------- ❑ LOWER--------------- ❑ SPACER, LOWER OTHER, DESCRIBE FINAL OPENED AT LBS. TEST CLOSED TIGHT----- ❑ CLOSED TIGHT----- ❑ REDUCED PRESSURE 2EMARKS: -9D FHE ABOVE REPORT IS CERTIFIED 0 T [NITIAL TEST PERFORMED BY���� DATE ZEPAIRED BY DATE -INAL TEST PERFORMED BY OF DATE STREET FILE 0 NAME OF PREMISES SERVICE ADDRESS CITY OF EDMONDS -- PUB•LIC WORKS DEPARTMENT AUG 13 1yyU BACKFLOW DEVICE TEST REPORT PUBLIC 61lO Ics i, / wM ui tYl'' 1.J I J LOCATION OF DEVICE1A4&-7- 1, %6q)Z-z DEVICE:15'*0 R�A fv -a -,z' & Manufac urer Mbdel Size Serial No. LINE PRESSURE AT TIME OF TEST _LBS. PRESSURE DROP AGROSS FIRST CHECK VALVE LBS. CHECK VALVE NO. 1 CHECK VALVE NO. 2 DIFFERENTIAL PRESSURE RELIEF VALVE :INITIAL 1. LEAKED ❑ 1. LEAKED ❑ 1. OPENED AT LBS. 'TEST 2 CLOSED•`TIGHT 2. CLOSED TIGHT 14.1 Z REDUCED PRESSURE ;s^ ; , 2. DID NOT OPEN O CLEANED ❑ CLEANED ❑ CLEANED REPLACED: REPLACED: REPLACED: DISC ------------- ❑ DISC ------------- ❑ DISC.UPPER---------- ------_--_-- SPRING - ❑ SPRING ❑ DISC. LOWER E GUIDE ------------ ❑ GUIDE --=--------- ❑ SPRING ------------------------=- El P PIN RETAINER ----- ❑ PIN RETAINER ----- ❑ DIAPHRAGM, LARGE A HINGE PIN -------- ❑ HINGE -PIN -------- ❑ UPPER------------------------- ❑ I SEAT ------------- ❑ SEAT------------- ❑ LOWER ------------------------- ❑ R DIAPHRAGM -------- ❑ DIAPHRAGM -=------ ❑ DIAPHRAGM, SMALL S OTHER, DESCRIBE -- ❑ OTHER, DESCRIBE -- ❑ UPPER------------------------- ❑ LOWER--------------- ❑ SPACER, LOWER OTHER, DESCRIBE FINAL OPENED AT LBS. ;TEST CLOSED TIGHT----- ❑ CLOSED TIGHT----- REDUCED PRESSURE THE ABOVE REPORT IS CERTIFIED INITIAL TEST PERFORMED'BY F REPAIRED BY 1INAL TEST PERFORMED BY OF /3 14 T dU / U DATE DATE DATE 11 STREET FILE CITY OF EDMONDS -- PUBLIC WORKS DEPARTMENT BACKFLOW DEVICE TEST REPORT AUG 131990-` PUBLIC ti4�0�"KS AP1E OF PREMISES ®�,�®6t,1 ,/�� �� o��� . ERVICE ADDRESS Z x1a �� ,� OCATION OF DEVICE //�O /�- EVICE: Ma nfiTcfc t urer Model Size Serial No. INE PRESSURE AT TIME OF TEST ij�b LBS. RESSURE DROP ACROSS FIRST CHECK VALVE LBS. CHECK VALVE NO. 1 CHECK VALVE NO. 2 DIFFERENTIAL PRESSURE RELIEF VALVE NITIAL 1. LEAKED Cl 1. LEAKED ❑ 1. OPENED AT ,a LBS. TEST 2. CLOSED TIGHT 2. CLOSED TIGHT REDUCED PRESSURE 2. DID NOT OPEN O CLEANED ❑ CLEANED ❑ CLEANED p REPLACED: REPLACED: REPLACED: DISC ------------- ❑ DISC ------------- ❑ DISC.UPPER------------------ R SPRING ----------- ❑ SPRING ----------- ❑ DISC. LOWER ---------------------- 0 E GUIDE ------------ ❑ GUIDE ------------ ❑ SPRING -------------------------- El P PIN RETAINER ----- ❑ PIN RETAINER ----- ❑ DIAPHRAGM, LARGE A HINGE PIN -------- ❑ HINGE -PIN -------- ❑ UPPER ------------------------- ❑ I SEAT ------------= ❑ SEAT ------------- ❑ LOWER ------------------------- ❑ R DIAPHRAGM -------- ❑ DIAPHRAGM- ------ ❑ DIAPHRAGM, SMALL S OTHER, DESCRIBE -- ❑ OTHER, DESCRIBE -- ❑ UPPER------------------------- ❑ LOITER--------------- ❑ SPACER, LOWER OTHER, DESCRIBE FINAL OPENED AT LBS. TEST CLOSED TIGHT----- ❑ CLOSED TIGHT- --- ❑ REDUCED PRESSURE EMARKS: iE ABOVE REPORT IS CERTIFIE 41TIAL TEST PERFORMED BY EPAIRED BY 1NAL TEST PERFORMED BY T OF�•as DATE DATE OF DATE /'7? 'STREET FILE / 6 /r / - 7s-1:4, le( CITY OF E®( ONDS 250 5th AVE. N. • EDMONDS, WASHINGTON 98020 • (206)771.3202 COMMUNITY SERVICES October 12, 1987 Scott Snyder Ogden, Ogden and Murphy 2300 Westin Building 2001 - 6th Ave. Seattle, WA. 98121 SUBJECT: MEADOWDALE MARINE Dear Scott: LARRY S. NAUGHTEN MAYOR PETER E. HAHN DIRECTOR Sometime ago you asked me to prepare an estimate for the work at Meadowdale Marine. I have recently come up with an acceptable design and have prepared a cost estimate. As you can see, it will be very costly. It is unfortunate we cannot share some of these costs with Meadowdale Marine. If you have no objections; we will take the Burlington Northern permit to the Council for authorization for the Mayor's signature. Very truly yours, JERRY W. H rTH, P.E. Hydraulics Engineer JWH/sdt Enclosure MMARINE/TXTST530 PUBLIC WORKS • PLANNING • PARKS AND RECREATION • ENGINEERING October 12, 1987 MEADOWDALE MARINE COST ESTIMATE Up to 75 L.F. 20".0 casing $ 8,500 Excavate bore'pit 6,000 Armoring by Burlington Northern Railroad 10,000 18' deep 72" 0 Type II ($1,360 + 980 + 980 + 430) 6,000 50 L.F. 1 1/2" 0 F.M. 500 50 L.F. 4" 0 F.M. 750 Pump/sump/controls 12,500 Pump/sump/control installation 2,500 Burlington Northern Railroad permit application 450 Crushed rock/ballast restoration 500 Burlington Northern Railroad flagging 5,000 G.I.P. 120 L.F. @ $6.00 L.F. 720 Elbow, straps, etc. 200 COSTEST/TXTST530 0 $53,620 . r,n3 rr�c-� • ,ro' � r .,y.CT7.. TO: FROM: RE: CO ■ Y OF E®Y ONDS CIVIC CENTER • EDMONDS, WASHINGTON 98020 • (206) 775-2525 CITY ATTORNEY November 8, 1985 Jerry Hauth City of Edmonds Scott Snyder Office of the City Attorney Meadowdale Marine/Phase I, Ltd. Sewer Connection TARRY S. NAUGHTEN MAYOR RECEIVED NOV 111985 ENGINEERING I discussed the sewer connection for Phase I with Dean Shepherd. Generally, because of the confused nature of the ownership of the railroad right-of-way, the legal issues may be much more complex than the practical solution. I suggested to Dean that he go to his client.and recommend, as I am recommending to you, that we find some way to divide the costs equitably between the Marina and the City. I posed our question for him as to why the City should bear full cost of this line when they are maintaining lines for other utilities in the same area. As a practical solution I propose that the City pay for the initial costs of construction while Phase I, Ltd. picks up the costs of current and future licenses and any repairs to the line itself. In this way we can limit our costs to initial contruction and allow Phase I, Ltd. to maintain both the easement and the line itself, as they maintain their other facilities. I would appreciate it if you would provide me with a written estimate of the construction costs necessary to extend our line to the Phase I edge of the Burlington Northern easement. WSS/naa 7 CITY.OF EDMONDS -- PUBLIC WORKS DEPARTMENT BACKFLOW DEVICE BEST REPORT NAME OF PREMISES SERVICE ADDRESS LOCATION OF DEVICE ate_ V Q4�-W A DEVICE: 1anu ac u er Model LINE PRESSURE AT TIME OF TEST _ LBS. .� PRESSURE DROP ACROSS FIRST CHECK VALVE �� _LBS. S-1714 Serial No. CHECK VALVE NO. 1 CHECK. VA_LVF IdO. 2 DIFFERENTIAL PRESSURE RELIEF VALVE INITIAL 1., LEAKED ❑ 1. LEAKED ❑ 1. OPENF.0 AT , 2, LBS. TEST REDUCED PRESSURE 2. CLOSED TIGHT' CLOSED TIGHT 2. DID ,NOT OPEN C1 CLEANED ❑ CLEANED ❑ CLEWIED U REPLACED: REPLACED:.. REPLACED: DISC -------------- ❑ DISC ------------- ❑ DISC.LIPPER-----------------------• C.l R SPRING ----------- ❑ SPRING ----------- ❑ DI SC.LO',!ER---------------------- I-- E GUIDE. =----------- ❑ (,UIDE--=--------- ❑, SPRIIIG-------------------------- G p PI^J RETAINER ----- O PIN RETAINER----- ❑ DIAPHRAGM, LARGE A HIi",GE PIN -------- ❑ HINGE- PIN - - - -- --- ❑ UPPER ------------------------- Ej I SEAT ------------- ❑ SEAT ------------- ❑ M-i'ER------------------=------ C1 R DIAPHRAGM.-------- ❑ DI.APHRAGM-------- ❑ DIAPHRAGM, SMALL S OTHER, DESCRIBE -- O OTHER, DESCRIBE -- ❑ UPPER------------------------- Cl LO';JER--------------- ❑ SPACER, LO',!ER OTHER, DESCRIBE FINAL.OPENED AT LBS. TEST CLOS.ED TIGHT----- ❑ CLOSED TIGHT----- ❑ REDUCED PRESSURE REMARKS: , y THE ABOVE REPORT IS CERTIF INITIAL TEST PERFORI.IED BY REPAIRED BY FINAL TEST PERFORMED BY v OF DATE DATE DATE 1 / 7 ,� LIV NAME OF PREMISES SERVICE ADDRESS TmEET FILE CITY OF EDMONDS IUBLIC,WORKS DEPARTMENT BACKFLOW DEVICE PEST REPORT LOCATION OF. DEVICE y e crk DEVICE. Pfac rurer 1 �ize� rial �o. LINE PRESSURE AT TIME OF TEST LBS. PRESSURE DROP ACROSS FIRST CI-.IECK VALVE __LBS. CHECK VALVE.P•J0. 1 CHECK VALVE 110. ? DIFFERENTIAL PRESSURE RELIEF VALVE .INITIAL 1., LEAKED ❑ 1. LEAKED ❑ 1. OPENED AT — __LBS. TEST a 2. CLOSED TIGHT' I ,, L. CLOSED TIGHT REDUCED PRESSURE 2 DID NOT OPEN CANED ElCLEANED LE ❑ CLL-A'lED U REPLACED: REPLACED: REPLACED:. DISC ------------- ❑ DISC ------------- ❑ DISC.LIPPER---------------------- [i R SPRING ------------ ❑ SPRING,—=--------- ❑ DI SC. L01-1ER------------•---------- E GUIDE•=----------- ❑ GUIDE ------------ ❑ ---------- SPRIPJG--.----------- --- P PIN RETAINER =---- ❑ PIN RETAINER----- ❑ DIAPHRAGM, LARGE A. HINGE PIP; -- - - - - -- ❑ HINGE. PIN -------- ❑ UPPER ------------------------- ❑ I SEAT ------------- ❑ SEAT ------------- ❑. LM-IER------------------------- 0 R DIAPHRAGH-------- ❑ DIAPHRAGM -------- ❑ DIAPHRAGH, SMALL S OTHER, DESCRIBE -- ❑ OTHER, DESCRIBE -- ❑ UPPER------------------------- LOI',TR--------------- U. SPACER, LOl•!ER I OTHER, DESCRIBE FINAL OPENED AT LBS. TEST CLOSED TIGHT----- ❑ CLOSED TIGHT----- ❑ REDUCED PRESSURE REMARKS: THE ABOVE REPORT IS CERTIFIED Tp BE TRU INITIAL TEST PERFORMED BY OF REPAIRED. BY FINAL TEST PERFORMED BY OF ,Flo.�' DATE � wo :� " • �� DATE DATE 1/7.1 STREET FILE CITYOF EDMOPIDS -- PUBLIC WORKS DEPARTMENT BACKFLOW DEVICE: I'EST REPORT NAME OF PREMISES b �QQL � ��/ Nle, SERVICE ADDRESS y ��i�i% *7, r, 4, LOCATION' OF DEVICE, C/C� . ' , DEVICE: Man fa &rer MbPIel. C7erial Po. LINE PRESSURE AT TIME OF TEST_^ _ � LBS. PRESSURE DROP ACROSS FIRST. CIIi:Ci,' VALVE LBS.. CHECKVALVE NO. 1 CHECK VALVE NO 2 DIFFERE1ITIAL PRESSURE RELIEF VALVE INITIAL l.. LEAKED O 1. LEAKED ❑ 1. OPENED AT LBS. TEST 2. CLOSED TIGHT 2. CLOSED TIGHT _ REDUCCU PRESSURE O 2. DID !,JOT OPEN CLEANED ❑ CLEAi•IED ❑ . CLEANED O REPLACED: REPLACED: REPLACED: DISC ------------- n DISC ------------- ❑ DI SC. UPPER ------------ , R SPP,ING----------- ❑ SPRING, ---------- ❑ DISC. LO:•IER----------------------- L7 E GUIDE ------------ ❑ GUIDE ------. ------- ❑ SPRIHG-------------------------- C P PII+ RETAINER ----- ❑ PIi'd RETAIidER ----- 0 DIAPHRAGI•I, LARGE A HI;,GE PIf--------- ❑ HII1;E PIN --=----- ❑ UPPER ---.--------------------- I SEAT -------=----- ❑ SEAT ------------= ❑ LO';IER------------------------- U. R DIAPHRAG-'I-------- ❑ DIAPHRAGM -------- ❑ DIAPHRAGI•l, SMALL S OTHER, DESCRIBE -- ❑ OTHER, DESCRIBE -- ❑ UPPER ----------- - ----------- 1-1 L0tli:R--------------- ❑ SPACER, LO';IER OTHER, DESCRIBE FINAL OPENED AT - LBS. TEST CLOSED TIGHT----- ❑ CLOSED TIGHT----- ❑ REDUCED PRESSURE REMARKS THE ABOVE REPORT IS CERTIFIED CEU INITIAL TEST PERFORMED BY ��D�doclDATEAl "-V/ REPAIRED BY DATE FINAL TEST PERFORMED BY OF DATE CI;RTI^ICATE #: Q d l 0 j 1 / 7 ,1 l i o.' STREET' FILE 4 CITY OF ED071ONDS -- PUBLIC lv:ORKS DEPARTH-,',!T p, p, C 1, 17 1. 0 DE':`; �7 EST REPORT '-S NAHE OF PREIIIS- SERVICE 'ADDRESS LOCAT I ONI OF DEVICE lJtVS;b-Illfloi�r Ac:--Ilzl 'c DEVICE: No. tlan"ufacturer c) dl e Size Serial LINE PRESSURE AT TIME OF TEST LDS. L 5 . PRESSURE .bROP ACROSS FIRST CHECK VALVE L S INITIAL TEST CHECK, Vt,LlF,O. I. LEAKED 2. CLOSED TIGHT I L' X CHECK V,'�,LVE 1:0. 1 LEAKED 2. CLOSED TIGHT 2 D - D-I Ei! "I AL )i),,-SSURE RELIEF VALVE — 1. cl, P E E F) T; �� i-I , �E/ -- -'� L B S Da—) PRESSURE 2'. D 11) IN OT O'? C L E : A r! E D IJ CLEANED 0 C L E A E D REPLACED: '..EPLACED: r Ln; C E D DISC - - - - - - - - - - - - - 11 Di SC - - - - - - - - - - - - - 0 1-. ; i F) -R ----------------- -'- -- L. 7 R S Pr!< I N G --------- El S P 1� I r.1 G ----------- rl'j Lil;ER ----------------------- E C-. U I D 7- --- 11 (,L] I DE ------------ 0 s I'lF, I :,it", -------------------------- p plN p[-r� I AINER ----- L J)T[d RETAINER ----- 0 D A 1-i T 1�� (- ;E P I �,' -------- F] -i -,E PIN -------- NC Cl U P R, ------------------------- I SEAT -------- ----- El SEAT ------------- El ------------------------- R D I A P H fn% A G "i -------- L-1 DIAPHRAG[l — ------- 11 I D 1'rk!) �4 $ OTHER, DESCRIBE L-1 OTHER, DESCRIBE --0 P'L.r -------------------------- -. 1) ,.' % --------------- -Z �: c C i I.Lil IBE FINAL 0 PEN D (I T LBS. TEST CLOSED TIGHT----- C-J CLOSED TlGHT----- El R E DU ED PRESSURE RE.MARKS;.- THE ABOVE REPORT IS CERTIFIED TO BE RU INITIAL -TEST PERFORMED BY 1 OF REPAIRED BY FINAL TEST PERFORMED BY OF 60 oj� 6 DATE JJ-j� DATE DATE 72'