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2. MUKILTEO WATER AND WASTEWATER DISTRICT

4. DATE OF TEST*
   DATE OF TEST
6. NAME OF FACILITY*
7. CONTACT PERSON
9. SERVICE ADDRESS*
10. CONDITION*

    1. NEW
    2. EXISTING
    3. REPLACEMENT
11. CATEGORY*

    1. RESIDENTIAL
    2. COMMERCIAL
13. CITY*
14. STATE
15. ZIP
16. PHONE#*
18. OWNER NAME*
19. OWNER EMAIL*
21. OWNER ADDRESS*
22. PHONE NUMBER*
24. CITY*
25. STATE
26. ZIP CODE
28. NAME OF TESTING COMPANY*
30. TEST EQUIP. MAKE*
31. TEST EQUIP. MODEL*
32. TEST EQUIP. SERIAL*
33. LAST CALIBRATION DATE*
35. CERTIFIED TESTER NAME*
36. CERTIFICATION #*
37. PHONE NUMBER*
38. EMAIL ADDRESS*
40. LOCATION OF ASSEMBLY*
41. DOWNSTREAM PROCESS*
43. TYPE*
    -- Select One --DCVADCDARPBARPDAPVBASVBA
44. MANUFACTURER*
45. MODEL*
46. SIZE*
48. SERIAL NUMBER*
49. OLD SERIAL NUMBER
50. WA STATE APPROVED*
    -- Select One --YESNO
51. PROPER INSTALLATION*
    -- Select One --YESNO
53. INITIAL TEST*
    -- Select One --PASSFAIL
54. CHECK VALVE LEAKS*

    1. NO. 1
    2. NO. 2
    3. NO LEAKS
55. CHECK VALVE 1 DIFF PSID*
56. CHECK VALVE 2 DIFF PSID*
58. RELIEF VALVE OPENED (RP)
    -- Select One --YESNO
59. RELIEF VALVE OPENED PSID (RP)
60. STATIC PSI DROP ACCROSS CHECK VALVE 1 (RP)
61. APPROVED AIR GAP PRESENT (RP)
    -- Select One --YESNO
63. CLEANED AND REPAIRED
    -- Select One --YESNO
64. NEW PARTS REQUIRED
    -- Select One --YESNO
65. NOTES
67. TEST AFTER REPAIRS
    -- Select One --PASSFAIL
68. CHECK VALVE LEAKS

    1. NO. 1
    2. NO. 2
    3. NO LEAKS
69. CHECK VALVE 1 DIFF PSID
70. CHECK VALVE 2 DIFF PSID
72. RELIEF VALVE OPENED (RP)
    -- Select One --YESNO
73. RELIEF VALVE OPENED PSID (RP)
75. CONFINED SPACE*
    -- Select One --YESNO
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

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