Document Redmond_doc_f0ac531114

Testing Procedure: 9th edition____ 10th edition____ ACCOUNT NAME OF PREMISES: Commercial  Residential  SERVICE ADDRESS: CITY: ZIP: CONTACT PERSON: PHONE: ( ) FAX: ( ) LOCATION OF ASSEMBLY: PROCESS: DCVA  DCDA  RPBA  PVBA  OTHER: NEW INSTALL  EXISTING  REPLACEMENT  OLD SER# PROPER INSTALL? Yes  No  MAKE OF ASSEMBLY: MODEL: SERIAL NO: SIZE: INITIAL TEST PASSED  FAILED  DCVA/RPBA CHECK VALVE NO.1 CLOSED TIGHT LEAKED PSID DCVA/RPBA CHECK VALVE NO.2 CLOSED TIGHT LEAKED PSID RPBA OPENED AT PSID #1 CHECK PSID AIR GAP OK? PVBA AIR INLET OPENED AT PSID DID NOT OPEN  CHK VALVE PSID NEW PARTS AND REPAIRS CLEAN REPLACE PART         CLEAN REPLACE PART         CLEAN REPLACE PART         CHECK VALVE HELD AT PSID LEAKED  CLEANED  REPAIRED  TEST AFTER REPAIRS PASSED  FAILED  LEAKED  PSID LEAKED  PSID OPENED AT PSID #1 CHECK PSID AIR INLET OPENED AT PSID CHK VALVE PSID AIR GAP INSPECTION: Required minimum air gap separation provided? Yes  No  Detector Meter Reading REMARKS: _ LINE PRESSURE_______PSI CONFINED SPACE? TESTER’S SIGNATURE CERT. NO. DATE TESTER’S NAME PRINTED TESTERS PHONE # ( ) REPAIRED BY CERT. NO. DATE FINAL TEST BY CERT. NO. DATE GAUGE CALIBRATION / / GAUGE# MODEL SERVICE RESTORED - YES  NO  I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. CITY OF REDMOND WATER QUALITY DEPARTMENT PHONE # (425) 556-2847 FAX # (425) 556-4222 Please return report to: City of Redmond MS: MOCPW PO Box 97010 Redmond, WA 98073-9710 Email: [EMAIL REDACTED]