20240913SWS to Staff 91 Supplemental Response - Test report 4.pdf

RECEIVED
Friday, September 13, 2024
• IDAHO PUBLIC J
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
i
SERVICE ADDRESS
LOCATION OF ASSEMBLY
SUPPLY
TYPE OF ASSEMBLY I 1 NEW INSTALL PSI
MANUFACTURER j I n MODEL L/ L L T SERIAL f( �. ,�, SIZE /
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST HELD AT PSID HELD AT-4-1-2--PSID OPENED AT PSID OPENED FULLY r.
CLOSED TIGHT Q CLOSED TIGHT DID NOT OPEN a DID NOT OPEN
LEAKED ❑ LEAKED ❑ CHECK VALVE HELD AT
LEAKED c
CLEAND r CLEAND ❑ CLEAND ❑ CLEAND ❑
REPLACED REPLACED REPLACED ❑ REPLACED r:
REPAIR/FINAL HELD AT PSID HELD AT PSID OPENED AT PSID AIR INLET OPENED AT PSID
CLOSED TIGHT ❑ CLOSED TIGHT u DID NOT OPEN u CHECK VALVE HELD AT
LEAKED r, LEAKED
PASS FAIL
NOTES
GAUGE p �^ �, MAKE AND MODEL t- r� `5 CALIBRATION DATE /
TESTER I ; LICENSE i i DATE
REPAIRED BY DATE
FINAL TFST BY LICENSE DATE
WATER PURVEYOR ! '
Nash & Son RPM
RFAI TOR •LANDSCAPING• EXCAVATION
Q\
A 208.500.9747
Call or Text for an Estimate
oz

Water File
Purveyor: n ►� I d a�, V l I i I I t No:
Service Address of assembly rl C 121 A Q,1— I2 4 .
Location of assembly on prernlse E�Y�-f—
Supply to (So r1 n K I GAS
Owner of assembly: t4 V e I'
Owner addtrss: Cj q.L V,' Cj
Manufacturer: Lv,-I 1� •h s Model No: 7J_3,/_L7 Size l Serial 2
Style: RP O DC)6- DCDA O RPDA O PVB O SVB O Orientation
New System Pressure
Install I ? 4Dojuble
Reduced Pressure Principle Assembly at this location
Y (� _PSI
heck Valve Assembly
I Check Valve#2 Relief Valve PVB/SVB
INITIAL Held at /, l PSID Held at 2- 3 PSID Air inlet
TEST Opened at PSID opened at
Closed light Closed tight -0-
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not o n U Check Valve
Comments:
Initial test by: Ch r i s N Q S h Date:
Certification/License# _V AT 2-0 4�b Pass Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
CertifuatiomVicense# Pass O Fail O
Water service restored? N
HAT Fam=mpk LW

Customer/Business Name: David'Tramblie Date: 5/9/2024
566 Stoneridge Rd �-
Assembly Service Address: Blanchard, ID 83804
Location of Assembly: R side
Type of Hazard Controlled:
Assembly info-Make: Ik '. Serial# 1► 18 �LV
RPBA RPDA DCVA DC IYC PVB SVB Size(In): Line Pressure(PSI):
Installation:Horizontal U N Vertical:VU VD �T Other:
New: Y/GD Replaces Serial #I:
Cheek Valve#1 Check Valve#2 RdW Valve _ P NlSVB Shut Off Valves
Initial ❑ Held at PSID ❑ Held at PSID ❑ Opened at peoed at
Test ❑ Closed Tight ❑ Closed Tight PSID PSID Closed Tight
Leaked Leaked Opened Fully 4Opined Fully
❑ Did Not Open [] D of Open Leaked ❑ ❑
Geld at
PS1D
❑ Leaked
❑ CLEANED ❑ CLEANED [] CLEANED ❑ CLEANED CLEANED
❑ REPLACED: ❑ REPLACED: [] REPLACED. REPLACED:
[] Disc Disc ❑ Disc ❑ Poppct/Float REPLACED []
❑ Spring ❑ Spring ❑ Spring [3 Air Inlet Spring
[� Guide Guide [] Guide ❑ Check Disc
w (] Seat ❑ Seat ❑ Seat ❑ Check Spring
e ❑ Hinge Pin ❑ Hinge Pin ❑ O-Ring(s) ❑ O-Ring(s)
a ❑ Module ❑ Module ❑ Module ❑ Guide
NOTES:
Final ❑ Closed Tight [] Closed Tight ❑ Opened At Air Inlela'S PSID Shut Off t Valves #1 #2�{
Test PSID PSID PSID CK Valve77_ PSID Closed Tight
NOTE:Purveyor must be notif K
ied wit fo4 hss of anxjbac w prevention assembly left in a failed(non-passim;)condition.
1
Testers Name(please print): ID BAT License
Company Name: SPRINKLERS NORTHWEST Expiration Datc:A42OL-1025 �Q Z
Company Phone: [phone] Email:
Test Equipment Make&Model: 1bt1"t63o K'5 u/�s fi Serial#:Ot tE�22 41 Q 2-1 q L(� -7
Calibratcd By: IAKQ--- Calibration Date:09/21/2023
I certify the wem wsa tested ra acordance with U S.C.tea pratoeot and vtvf to 11001%w l wnditiva!
Test Results: Passed Failed ❑ Assembly se Len: Water Service Restomdr!1 BAT Tax Ati—hedla-",
Saaatue of Tears Date
Covv of Report to: Customeryowner ❑ Water Purveyor ❑ Licensed Tester ❑
Water Purveyor:

Cumn=/Basin=Na=: Lew i D=: 2-1-23
A,,,=WV Service Addles SCOT - r i , a i lf)i c,,, [)CVi a rd ::1-b
LocationofAss=W ?-�clv\� a&f
TYPO Of Humd COWZO"- 1 Y�
A--%=bly info-M&T= (A)-,, M �-dj jlzb_ )-� Selo!9: L/
(cafe) RPEA RPDA DCVA DCDA cpri� size(10 3(4 Lis=Ptt=m(M:
Lf4 k(:.� s �
IrmUlation: N Verfical: VU 'V-D 01her.
Na . y -C-11�) r\rpL-.r-- 3=rW ii; - --- -
I Rnuivilm i PVBSEE sbctoffvahvs
i #1 #2
Held _PSID E]Held at _PSID 0 Cp=cdt zl;i,ImIct opcn=d at
Test 1-1 CJcr-cdTiZhI ❑ Limcd Tiw�,: -- PSrD PSM Clcr--dright
L=Icd 0 oppr--Oy Ray
E]D:d'.' -Opm r]Md Mw()?-
0 0
7,
r��Ezck held at
ZPM
0 L,-Aod
0 CLEANED 0 CLEANED CMAMM ❑CLEANED CLEANED
0 REPLACE E]REK-1 ❑RMACED. ❑RZK-ACED.-
❑D� []Me 0 r-i. ❑Poppet I FI.,-I REFI-ICED 0 E3
❑ spriog El Spin 1 0 spy ❑ Air Met Sprhm_
❑ Gtdd-. 0 Guide 0 Wdo- 0 Checs Mc
0 S= 0 scmi t El se- * 11 srr�----
EJ Fftir,-Pin 0 b&nci-M Ej(4&&) Ej-
0 Abdulc 0 (3-aid:
0- 0
0 cosed mght 0 OF..d At AjrjnjctPSI[ Shut Off'Valvw WJI 02
Test PSID PSID PSID C14:Valve PM ClosadTigW
NOTE:
Tester's Nam (pleaseprint): I-O ID BAT Lic=se Y
Comp a.n-Nmna:_P(-cL;, r i& Ccr-,4- C4-i)II F-Timfi n Dste: J;Z-2-W-:23
Compmy Phone: t?L)!."— Fat:
Test Equipment MaLc&Model: Serial
Calibrated By' %Y\O CnIihmfion Date:
I=
with U-S c zad V=j.we-in cXcaffi
Ted BAT T..q At-, -a
(Y71
s i-,_—w d Ic--r r Dr--
Cops of Report to: c Ucc=cd Testa x
Kmpth IdI*Px,.n=ml Water Plxlzfloo A--I--y T-1 Rqp t NMWP O-AK GS

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME j
SERVICE ADDRESS
J
LOCATION OF ASSEMBLY r
SUPPLY 1
� 1
TYPE OF ASSEMBLY NEW INSTALL PSI �—
MANUFACTURER , +� MODEL .� , SERIAL S12E
PVB/SVB I
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT r /PSID
INITIAL TEST OPENED AT PSID
HELD AT PSID HELD AT PSID OPENED FULLY �n
CLOSED TIGHT a CLOSED TIGHT ❑ DID NOT OPEN ❑
LEAKED r LEAKED DID NOT OPEN a CHECK VALVE HELD AT .Z•Z,
LEAKED u
CLEAND ri CLEAND ❑
REPLACED a REPLACED a CLEAND CLEAND❑ ❑
REPLACED REPLACED
REPAIR/FINAL HELD AT PSID HELD AT PSID r;
CLOSED TIGHT a CLOSED TIGHT �; OPENED AT PSID AIR INLET OPENED AT PSID
DID NOT OPEN ❑ CHECK VALVE HELD AT
LEAKED r. LEAKED
PASS FAIL
NOTES
GAUGE p ? MAKE AND MODEL CALIBRATION DATE
TESTER /�j��� ,^y .+ ^S LICENSE < DATE U Z
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR
Nash 81 Son RPM
T 1 ANOSICAVATION
208.500.9747
Call or Text for an Estimate

Water ( �7 File
Pun•et or: \('1 D n c �C d Q L UT I No:
Sendce.4ddress of assembly S1 J IVn c P_t G L�
Location of assembly on premise p oil_
supply to:S p r► n K l c►'S
Owner of assembly: C`'1 V C V,
Owner address: Sl � S I�a r-t d C1 t, Cib, D I an c h rx" ZIP Q 3 QO I
Manufacturer. Ln. l�.' , .Yodel No: :2 ZU 4 Size_�ISe rial 0 A l3 2 )(r
Stele: RP C DC C DCDA C RPDA C PVB $_ SVB C Orientation
New System Pressure
Installatuo t? Reduced Pressure Principle Assemble at this location
y j N PS!
�j Double Check Valve Assemble
Check Valve# l Check Valve#1 Relief halve P!'BISI'B
Held at PSID Held at PSID Air inlet
INITIAL '
Opened at PSID opened at 1 �
TEST Closed tight O Closed tight O
Did not open O Opened Fully�7
Leaked O Leaked O
Did not open E7
Check value
Cleared O Cleaned O Cleaned O held at j� L
REPAIRS Replaced O Replaced O Replaced 0 Leaked O
Cleaned O
Replaced C
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open C Check Valve
Comments:
Initial test by: Chas a n Date: 0 -2 2)
Certifrc•ation/License# W/T F 2 r�99) Pass' Fail C
Repaired/Cleaned by Date:
Final Test by: Date:
Certification/License# Pass C Fail C
Water service restored.q N
BAT Form sample LW

Water -h File
Parveyor: n.t `Q �(, U'h �� I I•[.� No:
Service Address ofassembly ��.1�'`( �51�r)� l' I (I Q L. 12C�
Location of assembly on premise
Supply
Owner of assembly: Arm weave
(�
Owner address: Liu-1 f h n Q r I o at y, City I C I ZIP.
Manufacturer: ki Model No: 007^ Size_L_Serlal �71l y
Style: RP O DC A2f DCOA 0 RPDA O PVB O SVB 0 Orientation
New ESysfem Pressure
Install? Reduced Pressure Principle Assembly is locationY ti PSI
Double Check Valve Assembly
Check Valve#111 Check Valve#2 Relief Valve PVB/SVB
--FL
INITIAL Held at Z •( PSID Held at 1 -2 PSID Air inlet
TEST opened at PSID opened at
Closed fight ,� Closed tight �
Did not open 0 Opened Fully O
Leaked O Leaked 0
Did not o n 0
Check valve
Cleaned O Cleaned 0 Cleaned 0 held at
REPAIRS Replaced O Replaced O Replaced 0 Leaked O
Cleaned 0
Replaced 0
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked 0 Leaked 0 Did not open 0 Check Valve
Comments:
Initial test by: Chris Nash Date:
CertifleadoWLicense# Pass�t Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
Certif cation/License# Pass 0 Fail O
Water service restored? N
BAT For.®pb LW

Customer I Business Name: Ann Weaver pate: 5/30/2024
Assembly service Address: 664 Stoneridge Road, Blanchard
Lomtion ofAssi:mhly: Right by road
Type oftiazard Controlled: Lawn Sprinklers
Asscmbly info-Make: 1,ti ,k, Model#: Serial#:
(cucici RPBA RPDA VAS DCDA PVB SVB Size In): Line Pressure IPSI):
Installation:Horizontal: �;' N Vertical: VIl VD Other:
I circle) New: Y Replaces Serial it:
Check Valve a 1 Check Valve 02 Relief Valve PVB/SVB Shut Oft Valves
aI a�
Initial ('�t lcld of LPSID, ❑ I Inld at_CAI PSID ❑Opened at ❑ Air Inlet opened at
'rest EfClosed Tight ❑ C'loscd Tight PSID PSID Closed Tight
❑ I raked Leaked ❑Opened Fully ❑ Opened Fully
❑Did Not Open ❑ Did Not Open Lcakcd ❑ ❑
❑ C'hodr held at
PSID
❑ Leaked
❑CLEANED ❑CLEANED ❑CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACED. ❑ REPLACED ❑ REPIACGU ❑ REPIACED
❑ Disc ❑ Disc ❑ Disc ❑ Poppet I Float R1,111ACED ❑ ❑
❑ Spring ❑ Spring ❑ spring ❑ Air Inlet Spring
❑Guide ❑ Guide ❑Guide ❑ Check Disc
`j ❑ Seat ❑ seat ❑Seat ❑ Check Spring
❑ Hinge Pin ❑ Hinge Pin ❑O-Ring(s) ❑ O-Rings)
❑ Module ❑ Module ❑ Module ❑ Guide
a ❑ ❑ ❑ ❑
tY NOTES: r
Final Z C cal Tight ❑Closedi Tight ❑ Opened At Air Inlet PSID Shut Off Valves 41 h:
Test PSID -CI1 P5IU 11SID CK Valve PSID ClosW Tight Q
NOTE:Purveyor must be notified within 24 hrs of any backtlow prevention assembly left In a failed(non-naasinit)condition.
Tesices Name(plew%e prim): Josh Mitchell ID HAT►.iecnse#: 19350
Company Name: Advanced Sprinklers Fxpiration Date: 1/1 0/2025
Company Phone: [phone] Fax#: [phone]
Test Equipment Make&Model: Midwest 845 Seria►#: 01120969
Culibrattxl By: BAT Calibration Date: 3/6/_2024
1 certify the assembly was tested in acordance witli U -.C.test protocol and was in working condition
Test Results: Passed ❑ Failed Assembly as Left: Service Restored ET---HAT"I u¢Attached��-
�I .
�SIWw ata un.
Copy of Report to: CustorncrrOwrtcr Watcr Purvv."t Licorictl Tester Tr
�- Water Purveyor: StoneridBe
North Idaho Raaiottal Warm Purvoyors aacknnw Assemhiv I cin Rerwxr NIRWPO-AM.6.S

a New
F77Existing
BACKFLOW ASSEMBLY TEST REPORT 0 Removed
F—iReplacement
Property CindyBell
Owner
Mailing 596 Stoneridge Rd Blanchard, ID 83804
Address
Phone [phone]
Assembly 596 Stoneridge Rd Blanchard, ID 83804
Address
a R P B.A ® D C V A [:] R P D.A O D C D A [::] P.V B A a S V B A[:3 A V B O AIR GAP
SIZE 1" MAKE Wilkins MODEL 350
Water Purveyor Stoneridge Prop. Water District Serial # A723295
Assembly Location: Meter
REDUCED PRESSURE ASSEMBLE' DOUBLE CHECK P.V B A SVBA INITIAL TEST
a1 CHECK INITIAL PRESS DROP (A) CHECK 01 AIR INLET CHECK PASSED
TEST RELIEF VALVE TIGHT ® 2.3 OPENED PRESS FAILED
RESULTS OPENED AT MIN2PSID (B) LEAKED O PSID AT DROP DATE
BUFFER PSDI PSDI as/DB-'24
A-B - CHECK 02
BYPASS MIN 3 PSI
TIGHT
CHECK RELIEF VALVE 2 5 DID NOT FAILED SYSTEMPtil
OPEN
PS-D ❑ 13
FADS ❑ FAI_ a I EAKED
COMMENTS
REPAIRS
AND/OR
PARTS
REDUCED PRESSURE ASSEMBLY D C A P V B A S V G A
AFTER
TEST
41 CHECK CHECK al REPAIRS
AFTER PRESS DROP iA) TIGHT PuID OPENED PRESS
REPAIRS RELIEF ❑ AT DROP DATE
OPENED ia;
MIN 2PSID CHECK 02 1 PSDI PSDI
BUFFER TIGHT PSID
A-B = 13 PASSED 0
MIN 3 PSI
IN COMPLETING AND SUBMITTING THIS TEST REPORT,THE TESTER CERTIFIES THAT
THE ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE RULES
AND REGULATIONS OF THE WATER SYSTEM,AND STATE REGULATIONS
GAUGE CALIBRATI N DATE 02-05-2024 DETECTOR METER READING
C. —/"�Yj
7rjTF ._i iNA'U
Tay or Fulwiler 12087777688 State Testers
Darnall Sprinklers Certification # BAT-23282
3172 W Setice Way Post Falls, ID 83854 Gauge # 02120756
REPORT RECEIVED BY ❑
SERVICE RESTORED
0 FOUND OFF, LEFT OFF

New
FTJ Existing
BACKFLOW ASSEMBLY TEST REPORT Removed
Replacement
'r°
Ow
y CindyBell
ner
Mailing 596 Stoneridge Rd Blanchard, ID 83804
Address
Phone [phone]
Assembly 596 Stoneridge Rd Blanchard, ID 83804
Address
ED I,P IT A ®III V A [::] N P 1;A a U i. I,A [=]P V[3 A C]IV fi A=AV B [:]A lk •AP
SIZE 11I MAKE Wilkins MODEL 350
Water Purveyor Stoneridge Prop.Water District serial« A723295
Assembly Location Meter
t,r ASSEMBLY 011UP61 14_Cn PVE :A INITIAL TEST
+'CHECK CHECK •T AIR INLET PASSED IM
INITIAL tEs3 DRcIP IAI
TEST r UEF VALVE TIGHT ®2 1 FAILED E3
AT
Pr,t
''ENEp AT lei LEAKED PSID AT DR_i
RESULTS
MIN2PSIp � DATE
�p
4FFBER _ C:rrr n =, vSn vSDI 05AB_/23
BYPASS MIN J PSI
i1C:Hi
CHECK ',hLIEFVALVE 9 W N' SYSTEM PSI
OPEN
. ❑ LEAKED C3 OSIU ❑ ❑ __��_._____
C(.)MMENT:-
REPAIRS
AND/OR
PARTS
+,I 1,1- 1. r4RESSURF A-, AFTER
TEST 91 CHECK
AFTER PRESS DROP IAI 1 ,1 i+s"a •'PENED cLI_y, REPAIRS
13 AT DROP DATE
'PAIRS RELIEF
OPENED l81
MIN 2 PSID GHEt-n e< PSDI PSDI
BUFFER TIGHT P54T
A'B • O PASSED
MNIPSI
IN COMPLE TING AND SUBMITTING THIS TEST REPORT.THE TESTER CERTIFIES THAT
T HE ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE RULES
AND RE(AILATIONS OF THE WATER SYSTEM.AND STATE REGULATIONS
GA S
CALIBRATION DATE O2-2S-2O23 DETECTOR METER READING
Ia
Dane Yallah 12087777688 State Testers
Darnall Sprinklers Certification II BAT-25372
3172 W Setice Way Post Falls, ID 83854 Gauge# 01191100
HCP,,RTRECENLL)BY ® SERVICE RESTORED
13 FOUND OFF,LEFT OFF
V/

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME ru p1 , 1 r" �1 �p� SC• ��
SERVICE ADDRESSclg A d /'G
LOCATION OF ASSEMBLY '1✓. , i
SUPPLY
TYPE OF ASSEMBLY NEW INSTALL PSI f?
MANUFACTURER MODEL C �/7 X L SERIAL S71jI� 7r SIZE
i
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 AIR INLET OPENED AT PSID
RELIEF VALVE
HELD AT /,,- PSID HELD AT /. i PSID OPENED FULLY c
INITIAL TEST CLOSED TIGHT of CLOSED TIGHT R- OPENED AT PSID DID NOT OPEN
LEAKED n LEAKED ❑ DID NOT OPEN ❑ CHECK VALVE HELD AT
LEAKED❑
CLEAND o CLEAND n
REPLACED o REPLACED L; CLEAND r, CLEAND �!
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED REPLACED❑ L:
SED TIGHT :. CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
CLO
LEAKED n LEAKED DID NOT OPEN ❑ CHECK VALVE HELD AT
PASS` FAIL
NOTES
GAUGE P MAKE AND MODEL �'?"' r CALIBRATION DATE L
TESTER ' ,, LICENSE
DATE �� /� 2
REPAIRED BY DATE
FINAL TEST BY LICFNSF DATE
WATER PURVEYOR I
Nash & Son RPM
a HF-AI TOR' •LANDSCAPING • LXC;AVATION
208.S00.9747
Call or Text for an Estimate

Water File
Purveyor: No:
Service Address of assemble 1 ��� J f j1 n to V 1 Ll
Location of assembly on premise_
Supply to: D YI Yl K I�L�
Owner of assembly: n i
Owner address: ftj?p ri
Manufacturer: 1--, 4,�, �_Mlodel No: Size_Z Serial_ t y -75—
Style: RP C DC 47 DCDA O RPDA C PVB C S[B C Orientation
New System Pressure
Install !' Reduced Pressure Principle Assembly at this location
Y LNPSI
Double Check Valve Assembly
Check F'alve# 1 Check Valve#2 Relief Valve PVBISVB
INITIAL field at Z, ( PSID Held at Z Y PSID Air inlet
TEST Opened at PSID opened at
Closed tight � Closed tight ,�_
Dirt not open D Opened Fully C
Leaked C Leaked C
Did not open a
Check valve
Cleaned O Cleaned C Cleaned C held at
REPAIRS Replaced C Replaced O Replaced C Leaked C
Cleaned O
Replaced C
FINAL Closed tight Closed tight Opened at_ .4ir inlet
TEST Leaked a Leaked C Did not open C Check Valve
Comments:
Initial lest by: Chris N Q S ► I Date: b 23
Certification/License# 13 Al 20 4 UJ Pass Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
Certification/License# PaKv C Fail C
Water service restored? N
BAT Form—pk PA

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
I^ !
SERVICE ADDRESS -}` -,C' C r '
LOCATION OF ASSEMBLY j
SUPPLY �.
TYPE OF ASSEMBLY L NEW INSTALL /J PSI _
MANUFACTURER ; MODEL Ov ?H'I 6' ,rl SERIAL jy SIZE
PVB/SVB
CHECK A VE#1 CHECK V E rY 2 L AIR INLET OPENED A7 PSID
INITIAL TEST
HELD AT�PSID HELD AT OPENED AT PSID
PSID RELIEF VALVE OPENED FULLY ❑
CLOSED TIGHT arj CLOSED TIGHT d' DID NOT OPEN ❑
LEAKED n LEAKED ❑ DID NOT OPEN ❑ CHECK VALVE HELD AT
LEAKED❑
CLEAND ❑ CLEAND ❑ CLEAND ❑ CLEAND n
REPLACED ❑ REPLACED a REPLACED ❑ REPLACED ❑
REPAIR/FINAL HELDAT PSID HELD AT PSID OPENED AT PSID AIR INLET OPENED AT PSID
CLOSED TIGHT ❑ CLOSED TIGHT ❑ DID NOT OPEN o CHECK VALVE HELD AT
LEAKED ❑ LEAKED ❑
PAS FAIL
NOTES
GAUGE# MAKE AND MODEL l��5 �-S CALIBRATION DATE
TESTER LICENSE /�A j s,�yI�S DATE 7 �CZ
REPAIRED BY �i DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR C ,. 'VJn,
Nash & Son RPM
REAITOR •LANDSCAPING •EXCAVATION
208.500.9747
Call or Text for an Estimate

Water File
Purveyor< n e I� d a c, Ufi I i tl c.j No:
Service Address of assexibly
Location of assembly on premiss
Supply to: (I o n n K I a
Owner of assembly: r I)(fiat_( ,J
Owner address: 2 D 1 I} vn c r ,( �[.-1 CWy � an aul zip qa S j
Manufacturer: L✓� S Model No: CTI,-P7/47 Siu__Seria!
Style: RP C DC�Li DCDA C RPDA C PVB C SVB O Orientation
New System Pressure
instaagt, ? Reduced Pressure Principle Assembly at this location
Y �jyf Jb PSI
Double Check Valve Assembly
Check Volve#l Check Val ve#2 Relief Valve PVB I SVB
INITIAL Held ar 2 , ( PSID Hdd at Z. $ PSID Air inlet
T Opened at PSID opened at
TEST Closed tight 0 Closed light
Did not open C Opened Fully O
Leaked O Leaked O
Did not open C
Check valve
Cleaned O Cleaned C Cleaned O held at
REPAIRS Replaced C Replaced O Replaced O Leaked C
Cleaned O
Replaced O
FINAL Closed right Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not o n 0 Check Valve
Comments:
Initial test by: Chris N Q S h Date: d J 3
Certification/License# 6C.�T 2 �} Pass'1 Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
Certifcatiom cease# Pass O Fail C
Water service restored? N
BAT Fam umpk LW

Customer/Business Name: Cindy Cunningham Date: 5/9/2024
89 Fairway Dr -
Asscrubly Service Address: Blanchard, ID 83804
Location of Assembly: by boulder @ drive
Type of Hazard Controlled:
Assembly info-Make: Serial# 34040
RPBA RPDA VA )CDA PVB SVB Size(In): Line Pressure(PSI): C�
Installation: Horizons. .U N Vertical:VU VD Other:
New: Y N Replaces Serial #;
T-- Check Vdve S1 Click Valve$12 ^�Rader Valve —_ PVB/SVB —— Sbat Off Valtns
Initial �Zl..d
tPSID He t?.y Z PSID � ❑ Opened at ❑ Opened atTest Tight Closed Tight PSID PSID Closed Tight
[� Leaked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
Did Not Open Did Not Open Leaked
❑ Check held at
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED } ❑ CLEANED CLEANED [] ❑
❑ REPLACED: ❑ REPLACED: E] REPLACED: ❑ REPLACED:
❑ Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide Check Disc
W ❑ Seat ❑ Seat ❑ Seat ❑ Check Spring
< [] Hinge Pin ❑ Hinge Pin ❑ O-Rings) ❑ O-Ring(s)
a ❑ Module ❑ Module ❑ Module ❑ Guidc
a ❑ ❑ ❑ ❑
�a NOTES:
Final Closed Tight Closod
Tight ❑ Opened At Air Inlet PSID Shut Off Valves #1 #2
Test /O PSID 2, yPSID PSID CK Valve PSID Closed Tight `
NOTE:Purveyor must be noti ed withifL24 h s of any backlLow prevention assembly left in a failed(oou-passina)condition.
Tester's Name(please print):4ji `3 r/;H QJI/ ID BAT License# .%l.L{�6 _
Company Name: SPRINKLERS NORTHWEST Expiration Date: --
Company Phone: [phone] Email: �--=—T
Test Equipment Make& Modrl:.lLA1GQ-MftS kec
Serial#:OtRC 2041441
Calibrated By: — Calibration Datc:09/21/2023
I ce t:r th ass ' was tatted in aeordsnce with U.S.C.teat protocol and was is wurltiog co moss
Test Results: Paucd Foaled ❑ Assembly as Left: Water Smice Raatoradj;� BAT Tag Atucheo�
vsaamee of'teuer Date `
Copv of Report to: CustontetK)wnet ❑ water Purveyet Licensed Tester ❑
Water Purveyor: STONERIDGE

Customer/Business Name: Cindy Cunningham Date: 5/11/2023
89 Fairway Dr —
Assembly Service Address: Blanchard, ID 83804
Location of Assembly: by boulder cL drive
Type of Hazard Controlled.-
Assembly info-Make: k0?�� S Serial# 34040
RPBA RPDA y VA , DA PVB SVB Size(In): Line Pressure(PSI):
Installation: Horizonta /Y N Vertical:VU VD Other:
New: N v Replaces Serial #
A'beck Valve#1 Check.Valve#2 Reller Valve _ PVB/SVB Shot Off Valm
� (,�
Initial lead at PSID ❑ Held at PSID ❑ Opened at ❑ Opetted at fii *I
Test Closed Tight ❑ Closed Tight PSID i PSID Closed Tight
!O Leaked (`Leaked ❑ Opened Fully ❑ Opened Fully
Did Not Open Did Not Open Lttaked
❑ Check held at
PSID
❑ Leaked
❑ CLEANED CLEANED ❑ CLEANED ❑ CLEANED CLEANED
❑ RFYL�1i cF_: A Tier ; I O l 2LA.cED; p REPLACED:
\ ❑ Disc sc ❑ Disc ❑ Poppet/Float REPLACED ❑ ❑
f
❑ Spring ring ❑ Spring ❑ Air inlet Spring
❑ Guide JZ Guide ❑ Guide ❑ Check Disc
❑ Seat ❑ Seat (] Seat ❑ Check Spring
Q Hinge Pin ❑ Hinge Pin ❑ O-Rings) ❑ 0-Ring(s)
❑ Module ❑ Module I ❑ Module ❑ Guide
NOTES:
Pinal C osed Tight Closed Tight �❑ Opened At Air inlet PSID Shut Off Valves #1 #2
Test � PSID 7 PSID PSID CK Valve PSID Closod Tight 2�
NOTE:Purveyor roust be notified within 24 hrs of any backflow prevention assembly left in a failted(non-pasalnit)condition.
Tester's Name(please print):RICHARD STAFFORD 1D BAT License;#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2023
Company Phone: [phone] Email:
Te%t Fquipment Make&Model: MIDW'EST 845 Serial#: 02191467
Calibrated By: B.A.T.&SUPPLY Calibration Date:09/24/22
I certify the as �b1y was tested in scordaucc with U.S.C.tent protocol and was in wo ' g eon oa.
Test Results: Passed Fail d ❑ Assambiv as Left: Water Service Reautred_ BAT Tax Anaehe _._
- Siattawe of Testnr Date
Copy of Resort to* Cwtomer/owm ❑ Water Purveyot ❑ Licensed Tester ❑
Water Purveyor: STONERIDGE

Customer/Business Name: Motor Coach Village Date: 5/9/2024
Blanchard, ID 83804 —
Assembly Service Address:
Location of Assembly:
Type of Hazard Controlled:
Assembly info-Make: U/ t nS Serial#
RPBA RPDA tCVA AtCDA PVB SVB Size(In): Line Pressure(PSI):
Installation: Horizontpl!y N Vertical:VU VD Other:
New: Y �� �� Replaces Serial #:
Check Valve#I Cbeck Valve WE Retfef Valve PV_BISVB_ Shut Off Valve$ _
Initial [�J4 a- 1C PSID H Opened at ❑ Ope eld at 2. PSID ❑ ned at al 'I M2
Test Iosed Tight 7ZClosed Tight PSID PSID Closed Tight f L
❑ Leaked Leaked Opened Fully ❑ Opened Fully
❑ Did Not Open Did Not Open Leaked ❑
El
❑ Check held at
PSID
❑ Leaked
n CLEANED ❑ CLEANED ❑ CLEANED CLEANED CLEANED
❑ REPLACED: ❑ REPLACED: ❑ REPLACED; ❑ REPLACED:
�] Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑ ❑
[] Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc
❑ Seat Seat ❑ Scat Check Spring
O ❑ Hinge Pin ❑ Hinge Pin ❑ O-Ring(s) ❑ O-Ring(s)
OG ❑ Module ❑ Module ❑ Module Guide
- ❑ ❑ ❑ ❑
NOTES:
Final dosed Tight f Closed :ight ❑ Opened.At Air Inlet PSID Shut Off Valves 0111 #2 Teat PSID 2_Z PSID PSID CKValve PSID Closed Tight d
NOTE:Purveyor most be notified within 24 hrs of any backflow prevention assembly left In a failed(non-passing)condition.
Tester's Name(please print): RICHARD STAFFORD 1D BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: B.A.T.&SUPPLY f Calibration Date:09/21/23
1 ceni fj.the aaarntbjt/wea weed in aemdance vnth U-S C 12V prokKol and was in workias co icon.
Teat Retain: Passed ty/ Assembly as Left: Watcr Service Rcstoeed( BAT Tag AnachestiEf"�
S.ps,—of T.—
CORV or Report to: Customer/Owner ❑ WSW P—vyx ❑ Licensed Tinter
Water Purveyor:

Customer/Business Name: Motor Coach Village Date: 5/9/2024
Blanchard, ID 83804
Assembly Service Address:
Location of Assembly: ! r Z—oOG�
Type of Hazard Controlled:
Assembly info-Make: W t� Serial# 2 Z 7
RPBA RPD DCDA PVB SVB Size(in): Line Pressure(PSI):—2A:o
Installation, Horizor alC__j---' N Vertical: VU VD Other:
New: Y fC) Replaces Serial #:
Check Valve#I Check Valve tl2 Relkf Valve PVBISVB Shut AR Valra
/ / / a l t:2
Initial r a{ SID VIC-.13d,
/ ( PSID ❑ Opened at ❑ Opened at �--�
Test Closed Tight .1ighI PSID PSID Closed Tight l i J )
❑ Leaked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑ ❑
❑ Check held at
__PSID
El Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACED: ❑ REPLACED: ❑ REPLACED: ❑ REPLACED.
❑ Disc ❑ Disc ❑ Disc Poppet i 1`10e1 REPLACED ❑ ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc
❑ Seat ❑ Seat ❑ Seat ❑ (:heck Spring
A ❑ Hinge Pin ❑ Hinge Pin ❑ O-Ring(s) ❑ O-Ring(s)
pt ❑ Module ❑ Module ❑ Module Guide
0. ❑ ❑ ❑ ❑
ai NOTES:
Final Closed Tight ,--osed Tight ❑ Opened At Air Inlet PSID Shut Off Valves #1 *2
Test Z_ja PSID jux PSID PSID CK Valve PSID Closed Tight ,©—
NOTE:Parveyor must be notified within 24 hn of any backflow prevention assembly left in a failed(son-passing)condition.
Tester's Name(please print):RICHARD STAFFORD ID BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: B.A.T.&SUPPLY Calibration r%te•00/21/23
I eanlfy tha ascembl u tested in eovrdance with U.S C ten protornl no was in working cvrt non
Teat Results: Passed ssembly as Iwft: water Swice Reskaol� BAT T.R Attsrhtsl&
Stp owcorTnter n.
Copv of Report to: CustomeriOwner ❑ Water Putveyvu ❑ Licensed T estet ❑
Water Purveyor:

Customer/Business Name: Motor Coach Village Date: 5/9/2024
Blanchard, ID 83804
Assembly Service Address:
Location of Assembly: R f �� { rct tic'ge - - - ---
Type of Hazard Controlled: R�
Assembly info-Make: Serial#A 0 5? i y
RPBA RPD(XrVA ►CDA PVB SVB Size(In): Line Pressure(PSI):
Installation: Horizonte} N Vertical:VU VD Other:
New: Y� Replaces Serial # —
Check valve Ml -- Cbaek Vatic#l2_ Retlaf Velve PVSIBVB Shut Off VaWa
kd
$1l #2
initial at PS1D atPSID ❑ Opened at ❑ Opetud atTest Closed fight ed Tight PSID PSID Closed Tight
❑ Leaked ❑ Leaked ❑ Opened Fully Opened Fully
❑ Did Not Open ❑ Did Not Open Lcaked
n Check held of
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED [] ❑
❑ REPLACED: ❑ REPLACED: ❑ REPLACED: ❑ REPLACED:
❑ Disc ❑ Disc ❑ Disc Poppet/Float REPLACED [] ❑
❑ Spring 0 Spring ❑ Spring Q Air Edit Spring
[] Guide ❑ Guide Guide ❑ Check Disc
w ❑ Seat 0 Scat Seat ❑ Check Spring
n Hinge Pin ❑ Hinge Pin ❑ O-Rings) ❑ O-Rings)
Module Module ❑ Module Guidc
s
qwC NOTES.
Fitsttl Closed Tight }� Tight Opened At Air Wei_ _PSID Shut OfTValves M1 #2
Test �l j PSID PSID _ PSID CK Valve PSID Closed Tight �� t
NOTE:Purveyor must be notified within 24 btrs of any backflow prevention assembly left in H sued(Don-passin¢)condition.
Tester's Name(please print):RICHARD STAFFORD ID BAT Licence# : 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: H.A.T. A SUPPLY Calibratinn Date-09/21/23
I centfy ttw a wu tared in aeoedanco With t1 S.C.test protocol and was in workina condition
'rest Results: Passed Failed ❑ Assembrv,as Left: Walla Service I-t,v Annrhe.d�
Due
5i�nus of Tara �_ .
Covv of Report to: Custamenownw ❑ W.Pttrveya- ❑ Licensed Tarcr
Water Purveyor-

Customer/Business Name: Motor Coach Village Date: 5/9/2024
Blanchard, II) 83804
Assembly Service Address:
Location of Assembly:
Type of Hazard Controlled:
Assembly Info-Make: I (� Serial# • Z 7 -7 4&
RPBA RPDA % DCDA PVB SVB Size(In):ia: Line Pressure(PSI):
Installation:Horizon N Vertical:VU VD Other:
New: Y EN
Replaces Serial #:
Check Valve
`M Check Valve Relief Valve PVB/SVB Shot Off Valve$
InitialZeld at�r v PS inIDd , PSID [j Opened at ❑ Opened at 42
-I --Test losed Tight dosed Tight PSID PSID Closed Tight
❑ Leaked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open Did Not Open Leaked ❑ ❑
❑ Check held at
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑
❑ RFPLACED: ❑ REPLACED: [] REPLACED. ❑ REPLACED:
[:] Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑ ❑
❑ Spring 0 Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc
E-] Seat ❑ Seat ❑ Scat ❑ Check Spring
Fn Hinge Pin Hinge Pin [] O Rings) ❑ O-Rings)
d
a ❑ Module ❑ Module ❑ Module ❑ Guide
❑ ❑ ❑ ❑ ��
9 NOTES:
Final Closed Tight ' C osed ight ❑ Opened At Air Inlet PSID Shut Of Valves #1 2
Test L J,--�PSID JLM PSID PSID ` CK Valve PSID Closed Tight
NOTE:Purveyor must be notified within 24 bra of any backfiow prevention assembly left in a failed(non-possine)condition.
Tester's Name(please print):RICHARD STAFFORD ID BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: B.A.T.&SUPPLY Calibration Date:09/21/21
1 certify the asum w"wood is scordmee with U.S.C.test protocol and wa1 in workins condium
Test Results: Passed /qFi led ❑ Ataambly as Leh: Wets Service Ratorcd BAT Tag Anaehedy
S - 9- 21
S,trWme ur Teemr Due
Copv of Report tn: CusiomedQwnef ❑ Waurthaveyw ❑ Licensed Tester ❑
Water Purveyor:

6stomer/BusinemName: Nlotfw Coach Village Date: 5/9/2024
Blanchard. ID 83804
Assembly Service Address:
Location of Assembl
y rr+
Type of Hazard Controlled:
Assembly info-Make: Serial#—2Q /
RPBA RPI DCDA PVB SVB Size(In): Line Pressure(PSI):
Installation:Horizont: C N Vertical:VU VD Other:
New: Y Replaces Serial #:
t
_ Cheek Valve#1 Cheek Valve#2 Relief Valve PVBISVH Shut Off Valve$
— #I #2
Initial �e d r 0 PSJD �d at .' /PSID ❑ Opened at ❑ Opened at
Test Closed Tight Closed Tight PSID PSID Closed Tight
❑ Leaked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open Did Not Open Leaked ❑ ❑
❑ Check held at
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED [] CLEANED ❑ CLEANED CLEANED [] ❑
❑ REPLACED: ❑ REPLACED: ❑ Wl ACED. ❑ REPLACED:
❑ Disc Disc ❑ Disc ❑ Poppet/Float REPLACED ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Intel Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc
❑ Seat ❑ Seat ❑ Seat ❑ Check Spring
❑ Hinge Pin ❑ Hinge Pin ❑ O-Rings) ❑ O-Ring(s)
A �] Module ❑ Module ❑ Module Guide
ix
❑ ❑ ❑ ❑
o� Norge: -
Flnsi Closed Tight asod TT'ght ❑ Opened At Air Inlet PSID Shut Ott'Valves #I #2
Teal PSID �t p PSID 1 PSID CK Valve PSID Closed Tight
NOTE:Purveyor must be notifled within 24 firs of any backilew prevention assembly left in a failed(non-pasalop)condition.
Tester's Name(please print): RICHARD STAFFORD ID BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: B.A.T.&SUPPLY Calihration Date:00/21/23
1 Certify the w,,em/' *ud in aeordaneo with U S.0 test protocol mtd was is working oon it6b.
Test Resulas: Passed �) Rule' ❑ Assembly as left: water Servico RostomQ-"" BAT Tag A"xeheA=
SipuNte or Teaa Dau
Copv of Report to: Customer:Qwttct ❑ Water Purveyor ❑ Licensed Testet ❑
Water Purveyor-

Customer/Business Name: Motarr-o-aeh Village Date: 5/9/2024
Blanchard, ID 83804
Assembly Service Address: /
Location of Assembly: L4—o 4- 3 3 T Pp c /
Type of Hazard Controlled: /�' �i� 7 1� q --
Assembly info-Make: e (/tom^ Serial# L
RPBA RPDA �CVA )CDA PVB SVB Size(In):—2.,---- Line Pressure(PSI):
Installation: Horizonta>l-, 1 N Vertical: VU VD Other:
New: Y Replaces Serial #
beck Valve f11 Cheek Valve#2 Rellef Valve PYHJBYs Shut Oft Valves _
Initial H d at PSID eld at //_` #� -2 j �_ '[� �lit�1D Opened at ❑ Opened et '
Test Closed Tighl [Closed Might PSID PSID Closed Tight �I
I-caked 0 Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑
❑ Check held at
PSID
1 [] Leaked
❑ CLEANED [] CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑ ❑
(] REPLACED: 0 REPLACED: [] REPLACED: [I REPLACED:
[] Disc ❑ Disc ❑ Disc [] Poppet I Float REPLACED ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
[] Guide ❑ Guide ❑ Guide ❑ Check Disc
w ❑ Sat ❑ Seat ❑ Seat ❑ Check Spring
G Hinge Pin ❑ Hinge Pin O-Ring(s) ❑ O-Ring(s)
❑ Module ❑ Module ❑ Module ❑ Guide
96 ❑ ❑❑ - ❑
a
z NOTES:
Finalloised Tig61 �.Ioscd l.Tight [] Opened At Air Inlet PSID Shut Off Valves ttl q2
Test 3 r PSID PSID PSID CK Valve PSID Closed Tight
_ NOTE:Purveyor most be notified wkbin 24 bra of any baeldlow prevention assembly left in a failed(non-passing)condition,
Tester's Name(please print):RICHARD STAFFORD ID BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:021914fi7
Calibrated By: B.A.T.&SUPPLY Calibration Date:09/21/23
1 w dfY the araem y was tsattd in seordance with u.s.C.test protocol and was in or king condition
Test Results: Passed F&" LCJJ Aasembly as i cm Water Service Restoredg/BAT TAR Atwched�'
sg+.n.rt of reran , Dot
Copy of Report to: Custamet%Ownet ❑ Water hir-cm ❑ Licensed Tester ❑
Water Purveyor-

Customer/Business Name: Motor Coach Villne Date: 5/9/2024
Blanchard, ID 83804
Assembly Service Address:
Location of Assembly: sfto 7'0
Type of Hazard Controlled: zk�
Assembly info-Make: y /� � n�r'� Serial#
RPBA RPDA CV DCDA PVB SVB Size(In): Line Pressure(PSI):
Installation:Horizontal: N Vertical: VU VD Other:
New: Y Replaces Serial #
Check Valve#1 Check Valve#2 RellefValve PVB/SVH Shut Orr Valves
#1 #2
Initial 1� at I , SID PSID ❑ Opened at ❑ Opened at
Test t Closed Tight C2,ltlosed Tight PSID PSID Closed Tight e/r
❑ Leaked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑ ❑
❑ Check held at
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACED. ❑ REPLACED: ❑ REPLACED: ❑ REPLACED:
❑ Disc ❑ Disc ❑ Disc ❑ Poppct/Float RE-PLACED ❑ ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc
W ❑ Sent ❑ Seat ❑ Seat ❑ Check Spring
C ❑ Htnge Pin ❑ Hinge Pin ❑ O•Ring(s) ❑ O•Ring(s)
❑ Module ❑ Module ❑ Module ❑ Guide
04 NOTES:
Final Closed Tight i�t)osed fight ❑ Opened At Air Inlet PSID ' Shut Off Val�va #I #2
Test PSID j PSID PSID CK Valve PSID Closed Tight
NOTE:Purveyor most be notified within 24 bra of any backilow prevention assembly left in a filled(non-passion)condition.
Tester's Name(please print):RICHARD STAFFORD ID BAT License# : 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial#:02191467
Calibrated By: B.A.T.Bt SUPPLY Calibration rate:09/21/23
I certify the assembly Metal in acordwae with US C tea protocol and was m workins condition.
Teat Results: Passed Failed ❑ Assembly at Lett: water Service RatomJ20' HAT Talt Ansoh-=
C/I
Sge►w:s a(7nnr Uate
Cupv of Report to: CmicitaedOwner ❑ wata Purvey., ❑ Licensed Tester ❑
Water Purveyor:

Custontcr/Businea,;Name. Motor Coach Village Date: 5/9/2024
Blanchard, ID i4804
Assembly Service Address:
Location of Assembly'. 9 C
'�1 �1�d % 14) ( Q
Type of Hazard Controlled:
Assembly info-Make: „ t Serial#
kl'BA HPDA iQ ; 1)C.U:1 PVB SVp Size(!n) 1.ine Pressure(PS1):6 _
Iu-�tallation: horizontal: N Vcnical:VU VD Other:
New: Y Replaces Serial
Y Cheek Valve I (.beck Valve M2 i Relief Valve PVWSVIB S6at Off Valves
Illltial ] I d ar�` l PSID — PS[D ❑ Upened at ❑ Opened at —
`t
Test i Closed Tight ,flu PSID PSID Closed Tight ler L_ �
Leaked ❑ lie ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open ❑ Did Nnt Open Leaked ❑ 00 '
~ti
❑ Check held at
PSID
❑ Leaked
-�-- —�-7— -- ---t— -
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLFANED CLGVNED ❑ ❑
❑ R,E}tLACGn: ❑ WLACL-D: ❑ R-ENLACED. ❑ REPLACED.-
❑ Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑ Q,
❑ Spring ❑ Spring ❑ Spring I ❑ Air Inlet Spring
❑ Guide ❑ Guide I ❑ CJuidc ❑ Check Disc
❑ Scat ❑ Seat ❑ Seat ❑ Check Spring
Q ❑ Ilinge Pin ❑ Hinge Pin ❑ 0-Ring(s) ❑ O•Ring(s)
❑ Module ❑ Module ❑ Module ❑ Guide
a NOTES: — - - — —— -
Final V `'Io Tight (�used Tight ❑ t�pened At Air Intet PSID 5but Off Valves 71
Test _.L PSID t PSID PSID CK Valve PSID Closed Tight E—
NOTE.Purveynr must be notified within 24 lirs of any backflow prevention assembly left In a failed(non-passine)condition.
Testers Name(please print): RICHARD STAFFORD ID BAT License n ; 1,41 45
Company Name: SPRINKLERS NORTHWRST Expirution Date: 10,125!20'_4
Company Phone: [phone] Email:
I est Equipment Make& Model: MIDWES-1 845 Serial#:02191467
t alihrmed liv IVA 1 & SUPPLY < aliLratinn Tl;q.• '1'7x
I certify the "tcatcd in awrdaace-lift u S c test protocol atmt wits in workuta wnditiun
Test Results: Pasted titaemb Failcd ❑ Assembly as left: Water Service Rcuured� BAT Taf AnachedCq---
saa.'oR ar truer � tr+:e
Cup%of Report to: customerfowner ❑ water Purveyor Cl Licensed Tester ❑
Water Purveyor-

Customer/Business Name: Motor Coach Village Date: 5/9/2024
Blanchard, ID 83804
Assembly Service Address: e—
Location of Assembly: 4 h C; 1 •� �! 1
Type of Hazard Controlled:
Assembly info-Make: /�(0 O TIQ Z Serial#
RPBA RPDA �ADA PVB SVB Size(In): Z Line Pressure(PSI):
Installation:Horizontal' N Vertical: VU VD Other:
New: Y Replaces Serial 4:
Cheek Valve#1 Clteck Valve#2 _ Rdlef Votive PVB/SVB Shut OH Valves
Initial &/, 1, at-PSID ❑ Held at�ID I ❑ Opened at ❑ Opened at
Test 2 Closed Tight ❑ Closed Tight PSID PSID Closed Tight
C I caked ❑ Leaked ❑ Opened Fully ❑ Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑ ❑
❑ Check held at
PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACW: ❑ REPLACED: ❑ REPLACED ❑ REPLACED:
❑ Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑ ❑
❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Check Disc '
❑ Seat ❑ Seat ❑ Seat ❑ Check Spring
< ❑ Hinge Pin ❑ Hinge Pin O-Ring(s) ❑ O-Rings)
❑ Module ❑ Module ❑ Module ❑ Guide
El El
OC NOTES: —- — -
40
VIA
Final l se:. Tight Closed Tight ❑ Opened At Atr Iulel PS1D Sbut Off'Valves #1 #2
Teat r PSID �. PSID PSID CK Valve PSID Closed Tight ,
NOTE:Purveyor must be notified within 24 bra of any backilow proventlon assembly left in a failed(non-passing)condition.`
Tester's Name(please print):RICHARD STAFFOR.D ID BAT License#: 18145
Company Name: SPRINKLERS NORTHWEST Expiration Date: 10/25/2024
Company Phone: [phone] Email:
Test Equipment Make&Model: MIDWEST 845 Serial 4:02191467
Calibrated t3y: B.A.f.&JUYYLY Calibration Datc:09/21/23
I cemfy the a trail as Crates Jo acordsme with U.B.C.lent protocol and wu in working con '
Tea Results: Passed Failed ❑ Awembly a Left: Water Service Restpta BAT Tag nunched�
tiranenue of 7aur Dnc
Cope of Report to: Customer/owner ❑ Water Purveyor ❑ Licemed Tcstct
Water Purveyor:

Water I }}-� File
Purveyor:�M n e �d Q�, V,�I I � (,� No:
Service Address of assembly l71
Location of assemhly on premise �(' n t 3 Ej"D n
Supply to: D rl n K I a
Owner of assemhly: [`-'1 L V r V-) V 1 0
Owner address: I Cj City. I (in rM Q zip gIgoj
Manufaerurer: (✓, !L.- 7 Model No: /2 -i-LI— size Z Serial z- j 7 7 S7`>,
Style: RP O DC fit DCDA O RPDA O PVB D SVB O Orientation
New System Pressure
Install Reduced Pressure Principle Assenrb!} at this location
Y (N PSI
Double Check I'alve Assemble,
Check Valve# 1 Check Valve#2 Relief[•aloe PI'B/SVB
INITIAL held at �,(, PS/D Held at -i,o PSID Air inlet
Opener/at P,S/D opened at
TEST Closed tight � Closed tight 1�
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at .4ir inlet
TEST leaked O Leaked 0 Did not open O Check Valve
Comments:
Initial test by: Chris N Q S h Date: d 23
Certification/License# 13 AT 2-04 UJ Pass Fail O
Repaired/Cleaned ky Date:
Final Test by: Date:
CertiJication/License# Pass O Fail O
Rater service restored?6N
PAT fm —plc L'A'

Water (� File
Purveyor: 1 U n e I�� Q t U� j No:
Service Address of assembly ti�C11, 1'( 0(11t V 111 a C1 C r
Location of assembly on premise (l i'l L `1 Yt n t-
supply to:
Owner of assembly:m oy `'( ()n w) Y 1 1 1 6 C �.
Owner address: M G TD Y C ("i n C h V I H 0 (1 City I� QrLI ZIP ,
Manufacturer: �n/� I (�.�. , Model No: D (9`7 3
Style: RP O DC 0- DCDA O RPDA O PVB O SVB O Orientation
New S;wtem Pressure
Install Reduced Pressure Principle Assemhlf at this location
Y PSI
Double Check Valve Assembly
—F
Check Valve# I ecliValve
Ch #l RelieJVdve PVB/SIB
INITIAL Held at L �7 PRsID Held at z- -f PSID Air inlet
Opened at P.S/D opened at
TEST Closed tight C Closed tight O
Did not open O Opened FuQy O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned D held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed right Closed tight _ Opened at Air inlet
TEST Leaked O Leaked O Did not o en O Check Valve
Comments:
Initial test bt,: Chris N Q S i I Date: V 23
CertiTcationlLicense# 13 f�T 2 0 4 UJ Pass�l Fail O
Repaired/Cleaned bl' Date:
Final Test bl,: Date:
Certiftcation/License# Pass O Fail O
Water service restored? N
BAT Form v pk LW

Water File
Purvryor. n (� Q�. Ufi �s No:
Service Address of assembly H DID r-c 0 a C i I I � G ( _
Location of assembly on premise LL(I' I Ci n L i-(I d r( I t
Supply to: CS v n n K I a
Owner of assembly: (1 r h y I I I Ck Q,t
Owner address: 1�LU tv c r�c�r I I I a C� f a n r, Ll�?iI ZIP QM-D
Manufacturer: 4.,,� Model No: ,.rD ,<e L( Size Z Serial 40 a v/
Style: RP O DC1V DCDA O RPDA O PVB O SVB O Orientation
New Inst ? Reduced Pressure Principle Assembly System Pressure
at this location
Y � Z_PSI
Double Check Valve Assembly
Check Valve#I Check Valve#2 Relief Valve PVB/SVB
INITIAL Held at / ,3 PSID Hdd at Z. f PSID Air inlet
TEST Opened at PSID opened at
Closed tight �- Closed tight �-
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O
Did not open O Check Valve
Comments:
Initial test by: Chris N Q 5 r l Date: "I V J3
CertifuationlLicense# 13 f�T 20 4 11b Pass,!' Fag O
Repaired/Cleaned by Date.-
Final Test by: Dare:
Cerditcationl tense# Pass O Fail O
Water service restored? N
BAT Foe aaepk LW

Water File
Purveyor: n.e d Q U I I ►iT) No:
Service Address of assembly 1 -j(')I-D
Location of assembly on premise
supplvto: (SDYI n KI CGS
Owner of assembly: 61 f 1TV CC O(L _ l I 10 G1:<
7
Owner address: P N n'i rt)a C I 11 C4 C1 C o1 w LI ZIP `Loi
Manufacturer: Model No: Size �— Serial ZZ7 7 y6&
Style: RP O DC L' DCDA O RPDA O PVB O S VB 0 Orientation
New System Pressure
Install Reduced Pressure Principle Assembly at this location
Y LN 2Y—PSI
Double Check Valve Assembly
Check Valve# 1 Chec�ralve# Relief Valve PVBISVB
INITIAL Held at 2"7j PSID Held at 2. `( PSID Air inlet
TEST Opened at PSID opened at
Closed[fight 7�Z Closed tight �--
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced a Replaced a Replaced L7 Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked a Leaked O Did not open 0 Check Valve
Comments:
Initial test by: Chris N Q S h Date: d _23
Certiric•ation/License# 13 A T 2-0 4 Lb Pass to Fail 0
Repaired/Cleaned by Date:
Final Test by: Date:
Certification/License# Pass O Fail O
Water service restored? N
J
BAT Form sample LR'

Prater File
Purveyor:y I V n e I Q�. V I I ( s No:
Service Address of assembly M( 7 r
Location of assembly on premise
Supply to: D Yi n K l a
Owner of assembly: .1 U I-L) C[I(1
Owner address: L City lI ad qAd ZIPA�Em
Manufacturer: Alodel,No: 00-7--1 1 Q.T Size 2_ Seha/
Style: RP O DCO DCDA D RPDA O PVB O SVB O Orientation
New System Pressure
Installs Reduced Pressure Principle Assemble at this location
Y ( —7o PSI
Double Check Valve Assembly
Check Valve# l Check Valve #2 Relief Valve PVB/SVB
INITIAL Held at—I PSID Held at 2, ( PSID Air inlet
TEST Opened at PSID opened at
Closed tight � Closed tight
Did not open O Opened Fully O
Leaked O Leaked O
Did nut o en O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS, Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed fight Closed tight Opened at Air inlet
TEST Leaked O Leaked O
Did not open O Check Valve
Comments:
Initial test by: Ch r is N Q 5 1" 1 Date: V 23
CerNftcationlLicense# 13/1 T 2 0-q b Pass Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
Certiftc•ation/License# Pass a Fail O
Water service restored? N
v'
BAT Form sample LN'

Water File
Purveyor:_�fmn t V-h I 11)iL No:
Service Address of assembly 11 L rc C I V { a
Location of assembly on prentlse n K I'L>lj I
Supply to: (S o n n K l a
Owner of assembly:
Owner address:M U Sl?Y D(a 1.l'1 VI I I �q .(� City L111(, Q I�7il ZIP_
Manufacturer. 4 o l J Model No: yb�J �37Z Size_�Serial C�f�(��I7
Style: RP O DC 417 DCDA O RPDA O PVB 1.7 SVB O Orientation
New Inst ? Reduced Pressure Principle Assembly System Pressure
at this location
Y � 7 o PSI
Double Check Valve Assembly
Check Valve#Ir I Check Valve#2r I Relief Valve PVB/SVB
-]
INITUL Held at Z- y PSID Held at 'i, ( PSID Air inlet
TEST Opened at PSID opened at
Closed tight � Closed tight !�
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O
Did not open O Check Valve
Comments:
Initial lest by: Chris N Q 5 h Date;• :9 1 V •2.3
Certifcation/License# Pass* Fail O
Repaired/Cleatted by Date:
Final Test by: Date:
Certi kWi,o&4Jcetse# Pass O Fail O
Water service restored? N i
BAT Fora smpk LW

Water ( I 1 ) File
Purveyor. y I V n e I�1 Q (. �/ I S No:
Service Address of assembly P I on) j ( ()n
Location of assembly on premises -� ��
Supply to: Q YI n K i a
Owner of assembly:
Owner address: M b 1U ( (!(1( n V I I I Gl 6 L Cityl=L4L Z1 ZIPA�Q�
Manufacturer: i,��ln Model No: O5(o to She Z, ,Serial2-
SO4e: RP O DC 0 DCDA O RPDA D PVB O SVB O Orientation
New System Pressure
� Reduced Pressure Principle Assemble
Install at this location
Y -7o PSI
Double ('heck Valve Assembly
---[Check Valve# I Check�-alye Relief Valve PVB/SVB
INITIAL Held at 2-12 PSID Held at Z.y PSID Air inlet
Opened at PSID opened at
TEST Closed tight Closed tight
Did not open a Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleated o Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced D Replaced O Leaked a
—— - Cleaned O
Replaced O
FINAL Closed tight Closed tight _ Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test by: 1.1 I( I S I V Q S 1 1 Date: U 2 3
Certification/License# Y) Pass\0 Fail D
Repaired/Cleaned by Date:
Final Test bv: Date:
Certification/License# Pass O Fail O
Water service restored? N
J
BAT Form sample LW

Water File
Pnrvcyvr: n e I dot U�1 I IT)f j No:
ServiceAddress ofassembly ` L 0 G ( h y d I U c,"(
Location of assembh+on premise
Supply to: n n K i a
Owner of assembly: W OR) Y C C) I n
Owner address: ��"�Y(L)el ( V1 V I I City l n cb ad ZIPq�
Manufacturer:4 a v�/o Model No: V�d Cn c/y� Size Z Serial 4
Style: RP O DC;3—DCDA O RPDA O PVB O SVB O Orientation
New System Pressure
Installgt Reduced Pressure Principle Assembh, at this location
Y �i '7 o PSI
Double Check Valve Assemble
Check Valve# 1 Check 6'u/re # ReliejValve PVB/SVB
INITIAL held at P.S/D Held at L- '--(_PSID Air inlet
TEST Opened at PSID opened at
Closed tight �` Closed tight ,�-
Did not open O Opened Fully O
Leaked O Leaked a
Did not open a
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight _ Opened at Air inlet
TEST Leaked O Leaked O
Did not open O Check Valve
Comments:
Initial test by: C h r I S N Q S I I Date: b 23
Certification/License# 13 AT 204 th Pass\p Fail 17
Repaired/Cleaned by Date:
Final Test bv: Date:
Certifcation/License# Pass O Fail O
Water service restored? N
L'
BAT Form sample 1 W

Water Flle
Purvryor:_ n e Q�. Ufi I t.j No:
Service Address of assembly �1 ur( L�/1 c I'1 V I I (a
Location of assembly on premise L.('l hP I'-
supply to: a P n n K I a%
Owner of assembly: O-JV► (.0 Cl C Iq V I I I r.l QC
owner add►rss: t`-t o 1U r r o n r.h i ► I Gi ci,c city&aaL Q C zIP.
Manufacturer: jL� Model No: C417,194da 4� Size Z Serial L,✓1�e w,/��/
Style: RP O DC d- DCDA O RPDA O PVB O SVB O Orientation
New System Pressure
Inst ? Reduced Pressure Principle Assembly at this location
Y� -7 a PSI
Double Check Valve Assembly
Check Valve#1 Check Valve#2 Relief Valve PVB/SVB
INITIAL Held at -')i.J PSID Held at '4. ( PSID Air Mid
TEST Opened at PSID opened at
Closed tight J11- Closed tight 0-
Did not open D Opened Fully O
Leaked O Leaked O
Did not open O
Check vdve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test by: Chris N Q 5 h Date: :9 1 d '23
Certification/License# B AT 20 41b Pass Fall L7
Repaired/Cleaned by Date:
Final Test by: Date:
Cen#1catfo&4Awrse# Pass O Fail O
Water service restored? N /
BAT Fom umk*LW

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME V'
SERVICE ADDRESS 'C f �''�•( �. 1. . / ( <
LOCATION OF ASSEMBLY 747 '
SUPPLY T
TYPE OF ASSEMBLY ` NEW INSTALL PSI )
MANUFACTURER .W(r I/ MODEL Ir SERIAL `,h �Y.-( SIZE
PVB/SVB
CHECK VALVJE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST
HELD AT 1, 11 OPENED AT PSID
PSID HELD AT q PSID OPENED FULLY
CLOSED TIGHT @ CLOSED IGHT is DID NOT OPEN DID NOT OPEN _
LEAKED ❑ LEAKED ❑ CHECK VALVE HELD AT
LEAKED❑
CLEAND CLEAND c CLEAND r_ CLEAND ❑
REPLACED o REPLACED REPLACED c REPLACED I;
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT .. CLOSED TIGHT c OPENED AT_PSID AIR INLET OPENED AT PSID
LEAKED LEAKED n DID NOT OPEN a CHECK VALVE HELD AT
(PASS FAIL
NOTES
GAUGE MAKE AND MODEL It MAKE_ - G.� � 1 , / ,3 `/ j � CALIBRATION DATE
TESTER )
LICENSE DATE
1
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR _ l
Nash & Son RPM
RFAI 1011 • I ANhSf'APINI:- EXCAVATION
f
208.S00.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME 1 _
SERVICE ADDRESS
LOCATION OF ASSEMBLY
SUPPLY
TYPE OF ASSEMBLY ` NEW INSTALL PSI
MANUFACTURER j MODEL , / :1 SERIAL / ( <j SIZE '
PVB/SVB
CHECK VAL E#1 CHECK VALVy RELIEF VALVE#2 AIR INLET OPENED AT PSID
HELD AT PSID HELD AT�� OPENED AT PSID PSID OPENED FULLY i
INITIAL TEST CLOSED TIGHT 0 CLOSED TIGHT -a DID NOT OPEN
LEAKED c LEAKED p DID NOT OPEN CHECK VALVE HELD AT
LEAKED u
CLEAND n CLEAND ❑ CLEAND ❑
REPLACED a REPLACED a CLEAND
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED Li REPLACED c
CLOSED TIGHT u CLOSED TIGHT a OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED r LEAKED ❑ DID NOT OPEN u CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE p �,C, MAKE AND MODEL �� + CALIBRATION DATE :2 L
TESTER �? I /�J�i LICENSE L DATE �) 2
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR '
Nash & Son RPM
RFAI.TOR" •t_ANDSCAPING•FXCAVATION
208.S00.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS
LOCATION OF ASSEMBLY r ^
SUPPLY _ rr«R 0.1
TYPE OF ASSEMBLY r�C NEW INSTALL 1 PSI
MANUFACTURER L�` , {� ' MODEL / f_� 701 r &-1 SERIAL C,%L, C)i SIZE 2 `
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
HELD AT L PSID HELD AT 1. a PSID OPENED FULLY a
INITIAL TEST CLOSED TIGHT p CLOSED TIGHT OPENED AT PSID DID NOT OPEN u
LEAKED ❑ LEAKED ❑ DID NOT OPEN u CHECK VALVE HELD AT
LEAKED❑
CLEAND n CLEAND ❑ CLEAND ❑ CLEAND ❑
REPLACED ❑ REPLACED ❑ REPLACED a REPLACED u
REPAIR/FINAL HELDAT PSID HELD AT PSID
CLOSED TIGHT � CLOSED TIGHT u OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED ❑ LEAKED DIDNOTOPEN ❑ CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE# MAKE AND MODEL /� CALIBRATION UATE
TESTER fi? 7 LICENSE " c.f L. DATE
REPAIRED BY DATE
FINAL TEST BY LICE NSF DATE
WAFER PURVEYOR
Nash & Son RPM
4 REAL TOR •I_ANDSCAPINc,-F)WAVATION
\ v
7208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS
LOCATION OF ASSEMBLY
SUPPLY1—
TYPE OF ASSEMBLY P) NEW INSTALL PSI <,
MANUFACTURER L_J �? MODEL �' I I l / .7 SERIAL C , SIZE
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
HELD AT :2 I PSID HELD AT REL
PSID OPENED IE PSID OPENED FULLY r
INITIAL TEST
CLOSED TIGHT & CLOSED TIGHT la DID NOT OPEN
LEAKED LEAKED ❑ DID NOT OPEN o CHECK VALVE HELD AT
LEAKED❑
CLEAND n CLEAND n CLEAND a CLEAND .1
REPLACED REPLACED a REPLACED ❑ REPLACED r
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT a CLOSED TIGHT ❑ OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED c LEAKED DID NOT OPEN ❑ CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE# ` C MAKE AND MODEL �, 4/t'J , �I`, CALIBRATION DATE
t,: V
TESTER it LICENSE 7 DATE ( <<S Z
REPAIRED Bti DATE
FINAI TEST BY LICENSE DATE
WATER PURVEYOR
Nash & Son RPM
! HFAI TCM •1 ANDSC:APIN(. •FwrAVATICIN
` v
7' 208.SOO.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS
� 5" C w/
LOCATION OF ASSEMBLY n ��
ire,t- � 'i �� I / -
SUPPLY �r '
TYPE OF ASSEMBLY NEW INSTALL PSI [:
MANUFACTURER S MODELS c" 5 SERIAL I; ` SIZE ,
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST HELD AT PSID HELD AT PSID OPENED AT PSID OPENED FULLY e
CLOSED TIGHT p CLOSED TIGHT DID NOT OPEN ❑
LEAKED r LEAKED ❑ DID NOT OPEN ❑ CHECK VALVE HELD AT
LEAKED❑
CLEAND n CLEAND CLEAND ❑ CLEAND ❑
REPLACED ❑ REPLACED REPLACED t. REPLACED n
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT ❑ CLOSED TIGHT c• OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED n LEAKED r. DID NOT OPEN ❑ CHECK VALVE HELD AT
CPASS FAIL
NOTES
GAUGE# C� MAKE AND MODEL 4�, ,�� �'�/( \ CAUBRAfioN DATE l
TESTER _ J� , ^ LICENSE ) ��� °.� DATE L / y 2
REPAIRED BY DATE
FINAL TEST BY LICENSE f DATE
WATER PURVEYOR S L, 1f �L , C �, l"C
Nash & Son RPM
REALTOR • LANDSCAPING• EXCAVATION
208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME V c,,d17 J5
C�
SERVICE ADDRESS v " I5 I , . L
LOCATION OF ASSEMBLY ' ,,- I I
SUPPLY 1 ,
TYPE OF ASSEMBLY i NEVI lt: " PSI
MANUFACTURER �1 ( ^ti MODEL f ! <--'-7 SIZE
PVB/SVB
CHECK VALVE#1 CHECK VA�VE#2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST
HELD AT 31)PSID HELD AT� OPENED AT PSID
PSID OPENED FULLY r.
CLOSED TIGHT I CLOSED TIGHT d DID NOT OPEN u
LEAKED ❑ LEAKED DID NOT OPEN o CHECK VALVE HELD AT
LEAKED❑
CLEAND r CLEAND o CLEAND ❑ CLEAND ❑
REPLACED u REPLACED ❑ REPLACED ❑ REPLACED ❑
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT u CLOSED TIGHT ❑ OPENED AT-PSID AIR INLET OPENED AT PSID
LEAKED o LEAKED ❑ DID NOT OPEN ❑ CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE$$ C)JJ/61,q MAKE AND MODEL �t 7 CALIBRATION DATE 3 p.
TESTER o /�� ^ LICENSE 9606 3 DATE z
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR t
Nash & Son RPM
RFAITOR' •LANDc;CAPING•EXCAVATi(-)N
■ N
208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME 1 .e.
SERVICE ADDRESS
LOCATION OF ASSEMBLY I j
SUPPLY (�, C
TYPE OF ASSEMBLY 1 1 L NEW INSTALL PSI
MANUFACTURER ! ., 5 MODEL Cr1 7/L1 SERIAL S `� ,1 SIZE
PVB/SVB
CHECK VALVE RELIEF#1 CHECK VALVE#2 AIR INLET OPENED AT PSID
y
HELD AT_ _LPSID HELD AT�_PSID OPENED FULLY ❑
INITIAL TEST CLOSED TIGHT c CLOSED TIGHT of OPENED AT PSID DID NOT OPEN
LEAKED r LEAKED DID NOT OPEN a CHECK VALVE HELD AT
LEAKED c
CLEAND ❑ CLEAND ❑ CLEAND c CLEAND
REPLACED ❑ REPLACED u
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED U REPLACED
CLOSED TIGHT u CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED r LEAKED n DID NOT OPEN CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE# v �� I �.� MAKE AND MODEL ini CALIBRATION DATE Z
TESTER nt 15 i✓ : .� LICENSE 2 DATE 2
REPAIRED BY DATE
FINAL TFST BY LICENSE DATF
WATER PURVEYOR `, T %�7-
Nash & Son RPM
REAI TOR' •L ANC7SCAP'Mr.• F Yf'AVATION
208.500.9747
Call or Text for an Estimate

Water 'l I91 File
Purveyor: S fiU Q I d V I Ao:
c
Sen,ic•e Address of assemble V 1 rLe V a rA s '2-- l
Location of assembh�on premise ��� ,-7 c/ 7✓g , A yv 54
Supph•to: Y I I LVJ
Owner oj'assembl V I h (.y as i 2
Owner address: v I n o4 a Ir4 S Z City I an (, A ? _ZIP 3 e
/
Manuf is turer: I v-1 1 Model No: GO-7�I q-T Size Zr Serial ( .i,✓r a���t��-
Sttde: RP O DC& DCDA O RPDA O PI,B O SVB O Orientation
New Reduced Pressure Principle Assentbll, System Pressure
Insktllaltn ? P at this g,_PSI location
Y l
Double Check Valve Assembly
Clreck I alve#I Check I alve#1 TRelief Valve PVB/SVB
—- _r
INITIAL held at PSID Held at _PSID Air inlet
TEST Opened at PSID opened at
Closed tight �' Closed tight 47
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned a Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked D
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test by: r h n S N a j h Date:
CertiTcation/License# ^ZS 7J 9� Pass & Fail O
Repaired/Cleatted kv Date:
Final Test by: Date:
Certiftcalion/License# Pass a Fail O
Water service restored Y N /
B,\T Purtn ssmplc l.N

File
Water
nre Puj or:� n e R I d G•(. U" � I (� No:
Serer/ce Address of assembly_ �
Location of assembly on premise !7 'C o�'
Sum;.to: r n
Owner of assembly: V R Q U Q I U f 2
Owner address: (i P�4 arzl Z Cinr W(A r L a V I ZIP_
Manufacturer: Alodel No: 0-)"7.-17/O7 Size Z Serial_23 1 Z t,0 �
Style: RP O DC DCDA O RPDA O PVB 0 SVB O Orientation
New Sl•stem Pressure
I►rstall Reduced Pressure Principle Assemble at Fein location
Y �u PSI
Double Cheek Valve Assembly
Check I"aloe# 1 Clieck l'alve#2 Relief Valve PVB/SVB
INITIAL Held at 17 P.S/D Held at 1 ,'2 PSID Air inlet
Opened a1 PS/D opened u1
TEST Closed tight � Closed tight �
Did not open O Opened Fully O
Leaked 0 Leaked O
Did not open 0
Check valve
Cleaned O Cleaned 0 Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked 0
Cleaned 0
Replaced 0
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked 0 Leaked 0 Did not open 0 Check Valve
Comments:
Initial test by: Lb r I S N Q d V) Date: r " 22�
Cerlificalion/License# F�� Z S j �� Pass Fail 0
RepairedlCleaned by Date:
Final Test btu: Date:
Certification/License# Pass O Fail O
Water service restorer Y N /
BAT Form sampk LW

Rater, r�(( ,},, n File
Purveyor: U� n d a,e U I I 1 i 0 l� Ao:
Service Address of assenrhll' Vy r �i
Location of assentblt• a n premise y✓wCJ
Sappl j•to: h � I t yj
Owner of assembhv: V I i"u`� QY tl�
Owner address:_ ( (� 3 City n(,I)GUI ZIP Q1 QiU�
;1lanuf4cturer: L3/'1 t" Model,Vo:C4-_)"7,1--7 _T Size Z Serial '40 y e J/
Style: RP O DC!#- DCD.A O RPDA O Pt B O S1 B O Orientation
New Reduced Pressure Principle Assemble System Pressure
Installa 'o ? P at this location
y � Double Check Valve Assemble PSI
L----------------Al - 7—
F�ec•k 1 �]
Check Valve#2 Relief!'aloe PVB/SVB
INITIAL Held at cb,C P.S1D Held at PSID Air inlet
TEST Opened at PSID opened at
Closed tight � Closed tight .�
Did not open O Opened Fully O
Leaked D Leaked a
Did not open O
Check valve
Cleaned O Cleaned a Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test hl>: Ch r l s N —Date: S 10
Certific•ation/Lieett.ce# b/ l 1 2�5 4 —Pass a Fail O
Repaired/Cleated be Date:
Final Test h1•: Date:
Certiftc•ation/License# Pass O Fail O
Water service restored(Y N
BAT F.m xmple LU'

Water r - File
Purv.gor U n I a (� l�� I L� No:
Service Address of assembh' V I O q arkS
Location of assembly on premise 7q✓
Supply to: n n �i,
Owner of assembly: y fU7 CA,r 4 ( I }}�� ,,I /1
Owner address: y I Kuy a 1 Cin' IJ �(A�hu Y Gt ZIPeV q
Alanufacturer: L,, 'f''h Model No:Cx--l7 A-i Cgc t Size _L_Serial 4 /10 U y
Style: RP C DC 46 DCDA C RPDA C PVB C SVB C Orientation
New Sl�stent Pressure
Itostallat' Reduced Pressure Principle Assembly at this location
y ( PSI
Double Check Valve Assembly
Check I ah e# / Check Vah e#2 Relief Valve 777r P I'B/S I'B
Held at PSID Held at Z v PSID Air inlet
INITIAL
Opened at PSID opened at
TEST
Closed tight M(_ Closed tight &-
Did not open O Opened Ftdl v O
Leaked C Leaked C
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced C
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test by: Ch r I S N a S► ) Date: 0 ' 3
Certircation/Lic•ense# DAT 2S3 I of Pass Fail a
Repaired/Cleaned b)> Date:
Final Test by: Date:
Certiftc•ation/License# Pass C Fail C
Water service restored? N
HAT Form sample I N

Water File
Purveyor: 4nn e e I CI U-h I I ti tJ No:
Service Address of assembly
Location of asrsemhll•on preonAe "T p� -i e e � �� .T11 6
supply to: 1 p i n t,��
Owner of assemb/v:�/10 b y a!A f I
Owner address: \fl n tTia{- ,f I Cit1'1 1 LnCh a1 U ZIP (BQ U
Manufacturer: Model,'Sir k--) Size_.Serial
Stele: RP O DC L* DCDA O RPDA O PF'B D SVB O Orientation
New System Pressure
Installat i r? Reduced Pressure Principle Assetnbli at this location
y PSI
Double Check Valve Assembly
Check I'aloe# 1 Check F'alve#2 Relief I'ah a PIT/SVB
—i
INITIAL lleld at Z,U PSID Held at ` t�PSID Air inlet
Opened at PSID opened at
TEST Closed tight D Closed tight D
Did not open D Opened Fidly O
Leaked D Leaked D
Did not open D
Check valve
Cleaned D Cleaned D Cleaned D held at
REPAIRS Replaced D Replaced D Replaced D Leaked D
Cleaned D
Replaced D
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked D Leaked D
Did not open a Check 6 ahe
Comments:
Initial test ny: Ch r ► s f h Date:
Certircation/License# Pass Z? Fail D
RepairedlCleaned by Date:
Final Test bv: Date:
Certiftcation/License# Pass D Fail D
Water sendce restorer/ y N /
BAT Forth sample LW

Water File
Purveyor: ifi n C � 1 CI I q�(/-� U�`l� i s
Service.4ddress of assembly \V I " (A 0► /ld 1
Location of assembly on premise
Supply to: Po i i 11\,K L
Owner of assembly:
Owner address: V�j24s i Ci(v 13 I a n c h ri ZIP 3 o
Manufacturer: L,\/ p, �,� 5 91odelNo: -12; ,,l-r Size Serial 1­/21 � �77
St[>le: RP O DC#_DCDA O RPDA O PVB O S VB O Orientation
New System Pressure
Installat {t? Reduced Pressure Principle Assembly at this location
�l Double Check Valve Assembly
Check I alve# l Check Valve#l Relief[Valve P['B/SVB
_j
1:�7TI,9L Held at PSID Held at I D PSID Air inlet
TEST // Opened at PS/D opened at
Closed tight L� Closed tight Z#-
Did not open O Opened Fully O
Leaked O Leaked O
Did not open a
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
(leaned O
Replaced D
FINAL Closed tight Closed ti;lu Opened at Air inlet
TEST Leaked O Leaked O
Did not open O Check !'ulre
Cunmtents:
Initial lest b)•: C h N f✓ I -Date: ��d 2
Certification/License# T 2 S� `} Pasty 7 Fail O
Repaired/Cleaned by Date:
Final Test by: Date:
Certification/License# Pass O Fail O /
Water service restored Y N /
BAT Form sampk LW

Water File
Purvey or: �I h� �i d i2 i- U 1 1 I i fi t No:
Service Address of assembly y I r u u a _f
Location of assembly on premise vti
Supply to: r l n
Owner of assembly: V yuU ay As
Owner address: Y i ward f I cioyIn n ( alZIP
Manufacturer: Ll -,rl Model No: 0 Size_ Serial S 6-7z
�—
Style: RP O DC 6- DCDA O RPDA O PVB O SVB O Orientation
New Reduced
Install ' tr Reduced Pressure Principle Assembly Sti•slenr Pressure
at tlkis 1 cation
Y PSI
Double Check Valve Assembh•
Check Valve# 1 Check Valve#2 Relief 1'alve71 PVB/SV'BLJ
INITIAL Held at Z, PSID Held at �PSID Air inlet
TEST Opened at PSID opened at
Closed tight �� Closed light ii
Did not open O Opened Fully O
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test ky: E b r i S N Q f rl Date:
Certific•ation/Lic•ense# 2 S 3 P11cc10 Fail O
Repaired/Cleaned hti. Date:
Final Test by: Date:
Certification/License# Pass O Fail O
II titer serric•e restored' Y N
BAT Form sample LW

BA/CKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS
LOCATION OF ASSEMBLYIr
SUPPLY S
i
TYPE OF ASSEMBLY c NEW INSTALL N PSI C f)
MANUFACTURER f .�C C Gi MODEL ��/,N r7 SERIAL G; 5'C'ZC SIZE
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 AIR INLET OPENED AT PSID
HELD AT 3. / PSID HELD AT3 RELIEF V E
INITIAL TEST PSID OPENED AT PSID OPENED FULLY
CLOSED TIGHT CLOSED TIGHT � DID NOT OPEN
LEAKED n LEAKED ❑ DID N T OPEN CHECK VALVE HELD AT
LEAKED e
CLEAND r CLEAND ❑
CLEAND r, CLEAND
REPLACED a REPLACED a
REPLACED REPLACED
REPAIR/FINAL HELD AT PSID HELD AT PSID
�-.
CLOSED TIGHT �.. CLOSED TIGHT ❑ OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED c LEAKED n DID NOT OPEN CHECK VALVE HELD AT
FAIL
NOTES
GAUGE# /JZ MAKE AND MODEL ! L' S f CALIBRATION DATE 1 y
TESTER (I f1n r LICENSES ATE� L
REPAIRED BY DATE
FINAL TEST BY LICENSE DATF
WATER PURVEYOR
Nash & son RPM
RFAI_TOR• •LANDSCAPING•EXCAVATION
208.500.9747
Call or Text for an Estimate

Water � Fill
Purveyor. No:
Service Address of assembly �����•���.� ��//U L
Location of assembly on pran�se
Supply to: 11-�9,, l
Owner of assembly: < �l ��y�'t� /-t o I9
Owner address: Cam' ZIP
Manufacturrr:rq�� Model No: yV/06 72 Sit Z Serial (j
Style: RP O Dr%!dIDCDA O RPDA O PVB O SVB O Orientation
New Reduced Pressure Principle Assembly �'��Pressure
Install at location
p N PSI
Double Check Valve Assembly
T7Check Valve#I Check Valve #2 Relief Valor PVBISVB
Ileld ar Z PSID Reid at 3. 3 PSID Air Ind l
IMTIAL
Opened at PSID opened ar
TEST
Closed tight Closed tight
Did not Open a Opoice Fully o
Leaked 0 Leaked 0
Dui nor open O
Check valve
Leaned a Cleaned 0 Cleaned 0 held at
REPAIRS Replaced O Replaced O Replaced O Leaked 0
Qtmud 0
Replaced 0
FINAL Closed tight Dosed fight Opened at Air inld
TEST Leaked O Leaked O
Did not open a Check Valve
Comments:
Initial test b —Day.—
Pass' Dt Fail!]
Repaired/Ckaned by Dare:
Final Test by: Dade
Certificarionlucense# Pass O Fail 0
Water service rector 7YN

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS /,✓ I W IOr `y uNk.
LOCATION OF ASSEMBLY f S• ./ L�
SUPPLY —Trr.
TYPE OF ASSEMBLY lJ Ij NEW INSTALL PSI - 5
MANUFACTURER _ MODEL rL/�' SERIAL 9 697 S17E J
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT •2• PSI[)
HELD AT OPENED AT PSID PSID HELD AT PSID OPENED FULLY c•
INITIAL TEST CLOSED TIGHT a CLOSEDTIGHT n DID NOT OPEN
LEAKED G LEAKED ❑ DID NOT OPEN CHECK VALVE HELD AT .'
LEAKED o
CLEAND n CLEAND c CLEAND ❑ CLEAND
REPLACED ❑ REPLACED
REPLACED a REPLACED
REPAIR/FINAL HELD AT PSID HELD AT PSID c
CLOSED TIGHT �i CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
CLO
LSED TIGHT
r LEAKED n DID NOT OPEN o CHECK VALVE HELD AT_
PASS FAIL
i,AUGE p V,�, �. I ( MAKE AND MODEL i1/� i, CAI IBRAIION 0A1F A—
IESTER LICENSE DATE
REPAIRED BY DATE
FINAL TEST BY !`IQ �•�v/ti LICENSE ` T' 3 DATE L !i( /�
WATER PURVEYOR I Q e r L ,� J
Nash 8� Son RPM
T ' •I ANr1C1 -AVATIf1N
v
208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS Ci ,L ( ✓ I L-, '' c _ j I i� !c I L -,c r ( 10 �J�,�� t
LOCATION OF ASSEMBLY / C �- i" f C-
SUPPLY -� t
TYPE OF ASSEMBLY �/ ��' NEW INSTALL PSI
MANUFACTURER Li 0 MODEL v�� SERIAL +OC 3� SIZE 1
PVB/SVB 7
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT l• PSID
INITIAL TEST
HELD AT PSID HELD AT PSID OPENED AT PSID OPENED FULLY r
CLOSED TIGHT CLOSED TIGHT ❑ DID NOT OPEN ❑
LEAKED r: LEAKED DID NOT OPEN CHECK VALVE HELD AT 2. l
LEAKED
CLEAND CLEAND a
REPLACED � REPLACED � CLEAND CLEAND
� n
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED ❑ REPLACED
CLOSED TIGHT .-. CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED LEAKED n DID NOT OPEN CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE p 1 1 I j MAKE AND MODEL 4 " � y CALIBRATION DATE
1 t
7e
TESTER LICENSE DATE
REPAIRED BY DATE
FINAL TEST BY (; r".J�✓ LICENSE IS f `, _� DATE i, 2
WATER PURVEYOR L� v _ < ( (✓/�►
Nash Son RPM
HFAI T(TN I ANDSCAPIN(,•FX(AVAT ION
u
208.500,9747
Call or Text for an Estimate
ju

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME `l 'InR
SERVICE ADDRESS (e/ J Q n� p� 5 �L
LOCATION OF ASSEMBLY
SUPPLY
TYPE OF ASSEMBLY 1 U & NEW INSTALL PSI 7 U
MANUFACTURER h, > MODEL � SERIAL 'C l� SIZE
PVB/SVB
CHECK VALVE# 1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT
INITIAL TEST
HELDAT - "•ii HELD AT PSID OPENED AT OPENED FULLY 10
CLOSED TIGH I CLOSED TIGHT ❑ PSID DID NOT OPEN
LEAKED LEAKED n DID NOT OPEN u CHECK VALVE HELD AT_
LEAKED
CLEAND n CLEAND r
REPLACED � REPLACED �; CLEAND r. CLEAND n
REPLACED c REPLACED :
REPAIR/FINAL HELD AT PSID HELD AT PSID
�.: � OPENED AT PSID AIR INLET OPENED AT_
CLOSED TIGHT CLOSED TIGHT
ISED TI n LEAKED n DID NOT OPEN CHECK VALVE HELD AT_
PASS FAIL
r; I
GAUGE p MAKE AND MODEL M C'w'/ �' CALIBRATION DATE j/� /�> l•
FESTER LICENSE ) DATE
REPAIRED BY DATC
-7/7FINAL TEST BY i ! r LICENSE 64,T DATE /7 Z C/
[WATERPURVEYOR
Nash 8� Son RPM
T -1 /1N11': r/�VAT-ttlN
V
208.500.9747
Call or Text for an Estimate
to

��Zf a7fonwvcc)
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME 5(i"N
SERVICE ADDRESS �i C/ f `, y /
LOCATION OF ASSEMBLY �-
SUPPLY � 6 4- ,
TYPE.OF ASSEMBLY P v f�5 NEW INSTALL PSI
MANUFACTURER !l p MODEL PV/3 c/ SERIAL 13 5L/yg tj SIZE
I 1'
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT Z PSID
INITIAL TEST OPENED AT PSID
HELD AT PSID HELD AT PSID OPENED FULLY �(
CLOSED TIGHT u CLOSED TIGHT n DID NOT OPEN u
LEAKED t. LEAKED DID NOT OPEN a CHECK VALVE HELD AT L
LEAKED u
CLEAND a CLEAND o CLEAND ❑ CLEAND a
REPLACED REPLACED u
REPLACED n REPLACED c
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT � CLOSED TIGHT u OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED n LEAKED DID NOT OPEN ❑ CHECK VALVE HELD AT
ASS FAIL
NOTES
GAUGE# 0 MAKE AND MODEL fo ryr-j— CALIBRATION DATE ';, b Ly
TESTER C1,1 ,,I LICENSE [ Z S y DAT[
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR/
Nash & Son RPM
n RFAL TOR I ANDq(-APING • FW-AVA.TICIN
17 208.500.9747
Call or Text for an Estimate

J BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME T13
SERVICE ADDRESS / tiC 7 _-L-T, 1 r j l
LOCATION OF ASSEMBLY
SUPPLY
TYPE OF ASSEMBLY NEW INSTALL PSI JJ1
MANUFACTURER �`, C MODEL SERIAL U SIZE
PVB SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT 7• '2 PSID
INITIAL TEST
HELD AT PSID HELD AT PSID OPENED AT PSID OPENED FULLY
CLOSED TIGHT CLOSED TIGHT L DID NOT OPEN DID NOT OPEN
LEAKED L LEAKED ❑ CHECK VALVE HELD AT
LEAKED r
CLEAND o CLEAND n_
REPLACED a REPLACED o CLEAND CLEAND
r. n
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED c; REPLACED u
CLOSED TIGHT � CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED r. LEAKED DID NOT OPEN CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE# C ( MAKE AND MODEL / ' 1 r C, CALIBRATION DATE
TESTER LICENSE DATE
REPAIRED BY DATE
FINAL TEST BY /�• ,^ LICENSE DATE jf 2
WATER PURVEYOR S (v -�` / W fe ✓J 1, n
r
Nash 8� Son RPM
T 1 ANf?9Lr-AVATION
n
v
7208.500.9747
Call or Text for an Estimate
lJ

Customer/Business Name. Resort Property Management Date. 5/9/2024
198 Ironwood Dr
Assembly Service Address: Blanchard, ID 83804
Location of Assembly. Right side
Type of Hazard Controlled:
Assembly info-Make: �-\ apollo PN/841 Serial# B94093
RPHA RPDA DCVA DCDA PVR SVn Size(In): Line Pressure(PSI):
Installation:Horizontal: ' N Venical: VU VD Other:
New: Y (N ) Replaces Serial #
_T �' Relfef Valve PVBlSVIi Shut Off Val#1
TT Check Valve MI Cheek Valve#2
Initial ❑ Held w PSID ❑ Held at PSID ❑ Opened at dOpened at
Test ❑ Closed Tight ❑ Closed Tight PSID PSID Closed Tight
❑ Leaked ❑ Leaked ❑ Opened Fully Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑ ❑
heck held at
2• 1 PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACED: ❑ IlEP1.Ati1 A: ❑ ttliPJe&CW, ❑ R£PL,ACED:
❑ Disc ❑ Disc Dine ❑ Poppet/Float REPLACED ❑ ❑
❑ Spring ❑ spring Cl Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide ❑ Guide ❑ Cheek Disc
W ❑ Seat ❑ Seat ❑ Sat ❑ Check Spring
4 ❑ Hinge Pin ❑ Hinge Pin ❑ 0-Ring(s) ❑ O-Rings)
a ❑ Module ❑ Module ❑ Module ❑ Guide
0. ❑ ❑ — ❑ — ❑
NOTES:
Fiaai ❑ Closed Tight ❑ Closed Tight ❑ Opened At T—Air Inlet 3•, PSID Shut Off Valves n 1 #2
Teat PSID l PSID PSID CK Valve '/ PSID Closed Tight
NOTE:Purveyor must be notified within 24 hrs of any backftow prevention assembly left in a failed(non-passing)condition.
Tester's Name(please print): DAN ROSE ID BAT License#: 23366
Company Name: SPRINKLERS NORTHWEST Expiration Date:4/20/2025
Company Phone: [phone] Email:
Test Equipment Make& Model: MAKO MK5 Serial#:02AC22040141
Calibrated 13y: MAKO Calibration Dow;09/21/2023
1 cmtify,the useenbly was«atcd in acordance with L'.S.C.ten protocol an wu is" ins condition
Tel Ina: Possed e'^'—' Failed ❑ Meeasbly as Left: Water Service Restare d AT Tog Attuchein-
5anawr of rur Dtlr
Coov of Reoort to: CWomenOwnet ❑ Water Purveyor ❑ Licensed Tester ( �
Water Purveyor: Stoneridge

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME Q
tiERVICE ADDRESS , fi
I OCATION OF ASSEMBLY
SUPPLY r,r , -�
TYPE OF ASSEMBLY FV C1 ;NEW IN ST PSI i L
MANUFACTURER MODFI I� I'` L��7 SERIAL SIZE j
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT__ _ PYI
INITIAL TEST OPENED AT PSID
HELD AT PSID HELD AT PSID OPENED FULLY n
CLOSED TIGHT c CLOSED TIGHT o DID NOT OPEN DID NOT OPEN
LEAKED n LEAKED n CHECK VALVE HELD AT
LEAKED
CLEAND o CLEAND CLEAND ❑ CLEAND ❑
REPLACED ❑ REPLACED REPLACED o REPLACED ❑
REPAIR/FINAL HELD AT PSID HELD AT PSID OPENED AT PSID AIR INLET OPENED AT PSID
CLOSED TIGHT o CLOSED TIGHT DID NOT OPEN o CHECK VALVE HELD AT
LEAKED n LEAKED
PASS FAIL
GAUGE# MAKE AND MODEL CALIBRAI ION DALE S
TESTER �r,,.z r -- LICENSE ! -(. y �, DATE
REPAIRED BY DATE
FINAL TEST BY LICENSE DATE
WATER PURVEYOR -f
Nash & Son RPM
RVAl TOR • LANDSCAPING:- CXCAVAIION
--S,
208.500.9747
Call or Text for are Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME Derr (, „ -y—/)
SERVICE ADDRESS �. /`J 1 l ✓c� Y r (� _�L�C; L JJ �1
LOCATION OF ASSEMBLY
SUPPLY
TYPE OF ASSEMBLY U �3 NEW INSTALL PSI S�
MANUFACTURER f + , (,' MODEL ( SERIAL flg3 70 3 512E 1
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT SID
INITIAL TEST c;PENEOAT PSID
HELD AT PSID HELD AT PSID OPENED FULLY r
CLOSED TIGHT CLOSED TIGHT DID NOT OPEN DID NOT OPEN
LEAKED c LEAKED ❑ CHECK VALVE HELD AT (_
LEAKED c
CLEAND CLEAND
REPLACED o REPLACED CLEAND CLEAND
r.
REPLACED REPLACED
REPAIR/FINAL HELD AT PSID HELD AT PSID
CLOSED TIGHT ❑ CLOSED TIGHT ❑ '.)PENED AT PSID AIR INLET OPENED AT �'•• I
LEAKED n LEAKED n DID NOT OPEN u CHECK VALVE HELD AT
PA55 FAIL
rd:)11•.
GAUGE p I I ' MAKE AND MODEL /i ` CALIBRATION DATE
TESTER LICENSE DATE
REPAIRED BY DATE
FINAL TEST BY (ftyff— (3 r:3 t,.j I LICENSE �� ��0'G V 3 _ DATE I 2
WATER PURVEYOR 1 ,
Nash & Son RPM
RFAt TOR' I AND5,CAPING• F XCAVATION
7208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME �., /
SERVICE ADDRESS
LOCATION OF ASSEMBLY Lc > d c
v �
SUPPLY %
TYPE OF ASSEMBLY NEW INSTALL PSI `�S
MANUFACTURER J MODEL �� �� SERIAL ��t� C2 7 SIZE /
PVB/SVB
CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST OPENED AT PSID
HELD AT PSID HELD AT PSID OPENED FULLY >a
CLOSED TIGHT CLOSED TIGHT c DID NOT OPEN ❑
LEAKED n LEAKED n DID NOT OPEN ❑ CHECK VALVE HELD AT-2
LEAKED❑
CLEAND a CLEAND CLEAND ❑ CLEAND ❑
REPLACED u REPLACED REPLACED ❑ REPLACED ❑
REPAIR/FINAL HELD AT PSID HELD AT PSID OPENEDAT PSID AIR INLET OPENED AT PSID
CLOSED TIGHT ❑ CLOSED TIGHT L DID NOT OPEN ❑ CHECK VALVE HELD AT
LEAKED n LEAKED n
PASS i' FAIL
NOTES
GAUGE a I C,C + MAKE AND MODEL �11J . ' ), - 4 CALIBRATION DATE
TESTER LICENS DATE
REPAIRED BY DATE
FINAL TEST BY P lu h J n LICENSE �`� 47 rl C, DATE
WATER PURVEYOR S 1 lJA�- _ L 1
Nash & Son RPM
.CAL TdR LANDSCAPING • EXCAVATION
208.500.9747
Call or Text for an Estimate

BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER NAME
SERVICE ADDRESS ] .7 �'t.' ((
LOCATION OF ASSEMBLY
SUPPLY ^ ,11 1
i
a
TYPE OF ASSEMBLY 1 VZ I1 NEW INSTALL PSI c9
MANUFACTURER I (J' MODEL U�� SERIAL 5 g 3 J( SIZE 1
PVB/SVB
CHECK VALVE At 1 CHECK VALVE at 2 RELIEF VALVE AIR INLET OPENED AT PSID
INITIAL TEST OPENED AT PSID
HELD AT PSID HELD AT PSID OPENED FULLY W
CLOSED TIGHT CLOSED TIGHT n DID NOT OPEN
LEAKED ❑ LEAKED OID NOT OPEN ❑ CHECK VALVE HELD AT �
LEAKED❑
CLEAND ❑ CLEAND ❑
REPLACED o REPLACED �� CLEAND r CLEAND
ti
REPAIR/FINAL HELD AT PSID HELD AT PSID REPLACED REPLACED
CLOSED TIGHT � CLOSED TIGHT � OPENED AT PSID AIR INLET OPENED AT PSID
LEAKED c LEAKED DID NOT OPEN a CHECK VALVE HELD AT
PASS FAIL
NOTES
GAUGE# ! ` j MAKE AND MODEL �/ : l `� CALIBRATION DATE
` , L
TESTER LICENSE DATE
REPAIRED BY DATE
FINAL TEST BY /t �� r J L�1 LICENSE ��Qr �� 1✓ DATE
WATER PURVEYOR t -`� (,!- `,ld lY �e r C-1
Nash & Sorg RPM
RFAI T(]R- •1 ANDSCAPINf: .FXCAVATrc)N
-X,
208.S00.9747
Call or Text for an Estimate

�0 h�son
Water Flue
Purveyor: No:
Service Ad km of assembly l vbn ,..
Location of assembly on prendse 11
� II
Supply to:
Owner of assembly: �t _\T✓\
Owner address. City /� ZIP
Man owfurer: �,�,� U Model No: ��V b 1 4 Site ', Serial 9 yG1
Style: RP O DC V DCDA D RPDA O PVB)U—SVB D Orientation
New System Pressure
Install Reduced Pressure Principle Assembly at this location
Y / J "i s' PSI
l./ Double Check Valve Assembly
Check Valve#I Check Valve#2 r Relief Valve P"ISVB
WT7AL Held at PSM Held at PSID Air inlet
Opened at PSID opened at 1.I
TEST Closed tight D Closed right D
Did not open D Opened Fatly If
Leaked D Leaked D
Did nos open D
Check valve
Cleaned D Cleaned D Cleaned D held at J L
REPAIRS Replaced O Replaced D Replaced D Leaked D
Cleaned D
Replaced D
FINAL Closed dgl+t Closed tight Opened at Air inlet
TEST Leaked D Leaked D Did not open D Check Valve
Comments
Initial test by: ✓1� l '14 Date:
Cert leation/License � Pass Fail D
Repalred/Cleaned by Date:
Final Test by: Date:
Certifrcation/License# Pass D Fail D
Water service restored Y N�
BAT Foxe UM*LW

�ja.wur
Water Q File
Purveyor:
Service Address of assembly �r 1
Location of assembly on p►emise �— -
Supply to: S(��' �, l� { w7
Owner of assembly: Ll� e.i1/
Owner addms: City ZIP
Mennfaentrer: .-,1 �� Model No:�� _- Size Serial �' J
Style: RP O DC O DCDA O RPDA O PVB�_SVB O Orientation
New System Pressure
Reduced Pressure Principle Assembly
Install at this 1 ion
Y � �7 PSI
Double Check Valve Assembly
Check Valve#I Check Valve#2 Relief Valve PVB I SVB
IMTL4L Held at PSID Held at PSID Air Inld
TEST Opened at PSID opened at ZL
Closed tight O Closed tight O
Did not open O Opened Fully 8y
Leaked 0 Leaked O
Did not open O
Check valve
Cleaned D Cleaned O Cleaned L7 held at L•I
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed fight Closed right Opened at Air Intel
TEST Leaked L7 Leaked 0 Did not o n O Check Valve
Comments:
Initial test by:
Cert Jcation/License l'.-f'�-�I , _Pass 2 _. Fail O
Repaired/Cleaned by Dale:
Final Test by: Date:
Certi,frcation/License# Pass O Fall O
Water service restored Y N
BAT Pas WOW%LW

wyVVVAAI
Water File
Purveyor: �' 1�1/1�1�� �i-� No:
Service Address of assenbly.
Location of assembly on pronise I t
Supply to:_�'(l:'u�_ iL.
Owner of assembly:
Owner address: CYty ZIP r
Manufacturer:� Model No: Vj J�'i Siu Serial �1—
Style: RP O DC V DCDA O RPDA O PVB fj -SVB O Orientation
New Reduced Pressure Principle Assembly System Pressure
Installa#W at this location
Y / J PSI
l./ Double Check Valve Assembly
Check Valve#1 Check Valve#Z Relief Valve FF PVB I SVB
WTUL Held at PSID Held nt PSID Air luld
TEST Opened at PSID opened at
Closed tight !] Closed tight O
Did not open O Opened Fully
Leaked O Leaked O
Did not open L7
Check valve
Cleaned O Cleaned O Cleaned O held at Z•!
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced D
FINAL Closed right Closed tight Opened at A/r inlet
TEST Leaked O Leaked O Did not open O Check Valve
Comments:
Initial test by: lv�1 1v y Date:
L
Cert cationllicense � j�-Z5 L� Pass Fail
Repalred/Cleaned by Date:
Final Test by: Date:
CertiftcationlUcense# Pass O Fall O
Water service restored Y N
BAT Fora umpk LW /
V

Fri,
W arer �' File
Purvej,or: �T�v� r .� - ,.� �' No: ----
Senice Address of assembly t-, 1'
Loea#on of assembly ott pretisise f r �7 �'
Supply to: i} ! z 'G
Owner of assembly: ��1 •�+ t
Owner address.__ City ZIP
Mantejacturer:�t f Model No: / U Ili Size / Serlal I,s y �Y 3
Style: RP V DC V DCDA 0 RPDA 0 PVB�SVB V Orientation
Nes+ System Pressure
Insralla ' Reduced Pressure Principle Assembly at this location
y >\T 7��PS!
Double Check Valve Assembly
Check Vdve#I Check Valve#2 ReliejValve PVB/SVB
INITIAL Held at PSID Held at _PSID Air inlet
Opened at PSID opened at I I I
TEST Closed rigl►1 O Closed fight L?'
Did not open 0 Opened Frtlly,6-
Leaked 0 Leaked U
Did not open V
-� — Check valve
Cleaned E' Cleaned (-7 Cleaned 0 held at I , �
REPAFR.`+ Replaced,0 Repla-,ed Gf Replaced CI Leaked© _
-! _ — -- Cleaned
- Replaced V
FINAL Closed tight Closed right Opened at Air inlet
TEST Leaked 0 Leaked O
Did not Teti D• Check Valve
Contments:
Initial test by: i i: ' --_Date: Cy 4f Z r
CertileationlUcense Q 7 2 y� Past Fail 0
Repo ireOlClenned by Date:
Final T'esr by: Date:
Certification/License# Pass O Fail 0
NOW
Water service restored N
=own .. __j
-_—`— PAT Fo sampk L0.'
V

GO-4
Water �` File
Purveyor: �,✓� '� /� L ti�_ No:
Service Address of assemble CL"'
Location of assembly on premise
Supply to: �Y�
Owner of assembly: �-- ✓�,
Owner address: CIO- ZIP
Manufacturer:f '�� 1 Mode!No:2 U L Site—_-4_Serlal
Style: RP C DC 0 DCDA C RPDA 0 PVB,6- SVB C Orientation
New System Pressure
Reduced Pressure Principle Assembly
Irrstalla ' at this location
Y � 1 (' PSI
Double Check Valve Assembly
Check Valve k Irii-Check Valve#2r I Relief Valve ri PVBISVB
INITIAL Held at PSID Held at PSID Air inlet
TEST Opened at PSID opened at
Closed dglu O Closed tight O
Did not open O Opened Fully
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned C Cleaned G held at 'L• r
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed dght Closed tight Opened at Air inlet
TEST Leaked D Leaked O Did not open O Check Valve
Comments:
Initial test by: 7 Date:
Certification/License �? l G Pass, FailO
Repaired/Cleaned by Date:
Final Test by: Date:
Certification/License# Pass O Fail C
Water service restored Y)N
BAT Fans SMWW LW /
V

�6 1 v�GS
Water File
Purveyor: T7�n e ✓, �.-� No:
Service Address of assex&ly 9 L) 1 r, n j ..
Locadon of assembly on premise
swpph'to: n (s' .v S
Owner of assetnbly:
Owner address: Clq� ZIP
Manufacturer._t'u i Model No:J)1/1' (-I/ Slu _L _Serlal 13 1 V G q
Style: RP D DC D DCDA D RPDA D PVB 0SVB D Orientation
New System Pressure
h�staA Reduced Pressure Principle Assembly at this anon
Y PSI
Double Check Valve Assembly
Check Valve#1 1—check Valve#2 Relief Valve PVB I SVB
WTUL Held at PSLD Held at PSID Air Inlet
Opened at PSID opened a!
TEST Closed tight D Closed tight D
Did not open D Opened Fully
Leaked D Leaked CO
Did not open D
Check valve
Cleaned D Cleaned D Cleaned D held at L-q
REPAIRS Replaced D Replaced D Replaced D Leaked D
Cleaned D
Replaced D
FINAL Closed tight Closed tight Opened at Air Inlet
TEST Leaked D Leaked D Did not open D Check Valve
Comments:
Initial test by: \� V• � � CiL1�- Date. L 1 �! L
CertiftcationlUcense j 1 �� (�, Pass Fail D
Repaired/Cleaned by Date:
Final Test by: Date:
Cent,Jleat on/License# Pass D Fail D
r—Water service restored Y N
BAT Form xmpk LW /

Customer/Business Name: Resort Property Management Date: 6/13/2023
198 Ironwood Dr
Assembly Service Address: Blanchard, 1D 83804
Location of Assembly:
Type of Hazard Controlled:
Assembly info-Make: V /f Serial# g94v�J7�
RPBA RPDA DCVA DCUA Vlf; SVB Size(in): .L Line Pressure(PSI): f-©
Installation: Horizontal: Y N Vertical: VU VD Other:
New: Y N Replaces Serial #:
T -- -O-
Check Valve Nl_ J Check Valve MT_ � Relief Valve_ PV_B/S_V --Sh
_B � ut Q Valves
Initial ❑ Held at — PSID ❑ Held at PSID ❑ Opened at Open at #I #2
Test ❑ Closed Tight ❑ Closed Tight PSID igA. PSID Closed Tight &I Q
❑ Leaked ❑ Leaked ❑ Opened Fully 8 Opened Fully
❑ Did Not Open ❑ Did Not Open Leaked ❑ ❑
B Check held at
,Z 4 PSID
❑ Leaked
❑ CLEANED ❑ CLEANED ❑ CLEANED ❑ CLEANED CLEANED ❑ ❑
❑ REPLACED: ❑ REPLACED: ❑ REPLACED: ❑ REPLACED:
❑ Disc ❑ Disc ❑ Disc ❑ Poppet/Float REPLACED ❑ ❑
i
❑ Spring I ❑ Spring ❑ Spring ❑ Air Inlet Spring
❑ Guide ❑ Guide 1 ❑ Guide ❑ Check Disc
❑ Seat ❑ Seat ❑ Seat ❑ Check Spring
G ❑ Hinge Pin ❑ Hinge Pin ❑ 0-Ring(s) ❑ O•Ring(s)
CG ❑ Module ❑ Module ❑ Module ❑ Guide
A.
IY NOTES: -- ---�-- ------ —
Final Closed Tight ❑ Closed Tight ❑ Opened At Air InletC PSID Shut OFF Valves #1 i12
Test PSID PSID PSID I CK Valve'Z�PSID Closed Tight
NOTE:Purveyor must be notified within U bra of any backfiow prevention assembly left in a failed(non-passing)condition.
Tester's Name(please print): NICK NAVAREL ID BAT License#:BAT-26182
Company Name: SPRINKLERS NORTHWEST Expiration Date:2/21/24
Company Phone: [phone] Email:
Test Equipment Make&Model: MAKO MK-5 Serial#:02AC22040142
Calibrated By: MAKO Calibration Date:3/2/2023
1 certify the assembly was tested in ewrdance with U.S.C.tat protocol and was in working con hon-
Test Results: Passed Failed ❑ Asserably as Left: Water Service RestoradN* BAT Tall AttachedS
2
sipmre of Teller otm
Copy of Report to: CustomerJOwner ❑ Water Purveyor ❑ Licensed Tester ❑
Water Purveyor: Y-J,.Xj-i�`��.

AC rnr
Water Flle
No:
- Service Address of assembly y ` ( t/y t 2' .2
Location of assembly on practise T
Supply to:
Owner of assembly: - \`I L U fV i
Owner address: /City ZlP
Manufacturer: j �oMo&l No: P Size Serial
Style: RP V DC 0 DCDA O RPDA 0 PVB*SVB O Orientation
New Install v Reduced Pressure Principle Assembly sat tem locationsur
Y ��PSI
Double Check Valve Assembly
Check Valve#I Check Valve#2 Relief Valve PVBISVB
INITIAL Held at PSID Held at PAD Air inlet
Opened at PSID opened at
TEST
Closed dght 0 Closed tight O
Did not open O Opened Fully 11•
Leaked 0 Leaked O
Did not open O
Check valve
Cleaned 0 Cleaned 0 Cleaned O held at L•I
REPAIRS Replaced 17 Replaced O Replaced 0 Leaked 0
Cleaned 0
Replaced O
FINAL Closed tight Closed tight Opened at Air Inlet
TEST Leaked 0 Leaked O
Did not o en O Check Valve
Comments:
Initial test by;
CertificadonlMeense �"�--✓ 7 ZPass Fail C1
Repalred/Cleaned by Date:
Final Test by: Date:
Cert leatiomTkense# Pass O Fail 0
Water service restored
SAT Paw on*LW
V

C r
Winer r File
Purvryor: No:
Service Address ojassembly Z.I t— I✓c..,��,,�.9 _
Location of assembly on premise � �f
Supply to: 5 1614 !L
Owner ojassembly: r ✓�
Owner address: Clty ZIP
Manz4 actnrer. ' 1lfodel No:1- G_q 4- Size _J_Serlal ?v
Style: RP Z7 DC O DCDA O RPDA O PF,�-P O Orientation
New Reduced Pressure Principle Assembly at t IN Pressure
Install his to no
P 1 IPSI
Double Check Valve Assembly
����
Check Valve#2 Reliej Valve PVB I SVB
�. Held at PSID Held at PSID Air Mid
Opened at PSID opened at 1.O
TEST Closed tight O Closed tight O
Did not open O Opened Fupy fi�-
Leaked O Leaked O
Did not open O
Check valve
Cleaned O Cleaned O Cleaned O held at 15
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Alr inld
TEST Leaked O Leaked O Did not o n O Check Valve
Comments:
Initial test by:--L Date:
CmelcationAlcense >� 1 ���? � Pass*— Fail
Repaired/Cleaned by Date:
Final Test by: Date:
CertykatronAlcense# Pass O Fail O
Water service restoredf Y N
BAT FamuwkLW /
v

LYLT
Water File
Purveyor: No:
- Service Address of assembly. y a,
Location of assembly on premise
Supply to: Sr0,0 •✓1 � Imo.✓`-�
Owner of assembly: ✓t',7
Owner address: ����??'�'�,,��,� City ZIP
Manajacturer: �J Model No: ? .Size_jSeria( l
Style: RP O DC 0 DCDA O RPDA O PVR I!�SVB O Orientation
)ns[Nll w Reduced Pressure Principle Assembly Syt t ee.m Pr�ion
ure
Y � Double Check Valve Assembly 1 J�I
Check Vdve#1 Check Valve#2 Relief Valve rl PVB I SVB
IM7.UL Held at PSID Held at PSID Air Intel
Opened at PSID opened atTEST Closed tight O Closed tight O
Did not open D Opened Fully
Leaked O Leaked O
Did not open O
Check valve
Cleaned 47 Cleaned O Cleaned O held at 2-(
REPAIRS Replaced O Replaced O Replaced O Leaked O
Cleaned O
Replaced O
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked O Leaked O
Did not o n O Check Valve
Comments:
] �� Z
Initial test by: L� r
Date:
Cert fcatlon/License �� "�S ZI T Pais Fail 17
Repalre&Cleaned by Date:
Final Test by: Date:
Cerdfication, cease# Pass O Fail O
Water service )N
BAT Tom mrok LW J
V

S56,044
Water Rk
Purveyor: No:
Senice Add►aess of assembly 2 V"U .� w j .c+
Location of assembly on premise/- —)
Supply to: �✓-O✓n 4- (LAY
Owner of assembly: L�iT
Owner address: City ZIP
Manstfaeturen A�i. �� Model No: �1 Sl7e Serlal 1 j j
Style: RP D DC O DCDA D RPDA D PVBh—SVB D Orientation
New Reduced Pressure Principle Assembly Systetn Pressure
Insta at this location
Y N PSI
Double Check Valve Assembly
Check Valve 1 Check Valve#2 Relief Valve PVB ISVB
INITL4L Held at PSID Held at PSID Air bdet
TEST Opened at PSID opened at
Closed tight D Closed tight D
Did not open D Opened fltuy)6•
Leaked D Leaked D
Did not open D
Cheek valve
Cleaned D Cleaned D Cleaned D held al -L•Z
REPAIRS Replaced O Replaced D Replaced Ll Leaked D
Cleaned D
Replaced D
FINAL Closed tight Closed tight Opened at Air inlet
TEST Leaked D Leaked O Did not open D Check Valve
Comments:
Initial test by: Date: � l , (, Z
CertiJicationlucense I�( '� .Z'� 7 l Pass Fail D
Repaired/Cleoned by Date:
Final Test by: Date:
Ceri lcation/Llcense# Pass D Fail D
Water service mtoredf Y N
BAT Pam anple LW I