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oUJE�15 � <br /> OWENS COMPANIES, �N�. BACKFLOW PREVENTER <br /> 930 East 80`"Street TEST REPORT <br /> Bloomington,MN 55420-1499 <br /> - 952-854-3800 Fax:952-854-3769 <br /> �, � www.owensco.com �RL�!-�WA-�'2'� ��+4�t-►>la�.� <br /> \ Locally Own�d�- Nafionally Recognized- Since 1957 <br /> Work Order Number: ��'�,,7 Date: � � <br /> Name: i1� '�--1\ A�y+> Home Phone: <br /> Address: � �� 1 ' "�v'� Work Phone: <br /> Ci , State,Zi : ' ,A- Cell Phone: <br /> Location of service if different: ^ �L � � f� Email: <br /> Make and Model of Device: -�� , � Size: � Serial No.: <br /> Check Valve#1 Check Valve#2 Pressure Differential Pressure Differential Strainer <br /> , �} Across#1 when Relief Opens <br /> Test Befo�e Leaked ❑ Leaked ❑ None ❑ <br /> Repair <br /> P.S.I. P.S.I. <br /> Closed ❑ Closed ❑ Cleaned ❑ <br /> Describe (� 1lp� <br /> Repair: � p�.� � 'U�V'� '-� J � <br /> Leaked ❑ Leaked ❑ <br /> Final Test ��� P.S.L `� P.S.I. <br /> - Closed ❑ Closed ❑ <br /> Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: <br /> Replaced: ❑ Replaced: ❑ Replaced: ❑ <br /> � Disc ❑ Disc ❑ Disc: ❑ <br /> � Spring ❑ Spring ❑ Upper ❑ <br /> Guide ❑ Guide ❑ Lower ❑ <br /> Pin Retainer ❑ Pin Retainer ❑ Spring ❑ <br /> 'o Hinge Retainer ❑ Hinge Retain�r ❑ Diaphragm: ❑ <br /> m <br /> E ❑ , <br /> � Seat ❑ Seat ❑ Large: <br /> a <br /> ` Diaphragm ❑ Diaphragm ❑ Upper ❑ <br /> °' ❑ ❑ Lower ❑ <br /> � <br /> ❑ ❑ Small ❑ <br /> ❑ I ❑ Seat: ❑ <br /> ❑ 1 ❑ Upper ❑ <br /> ❑ �_❑ Lower ❑ <br /> ❑ �_❑ Spacer: ❑ <br /> � _t� Lower ❑ <br /> .--;• <br /> Final Test Opened at_Ibs <br /> Closed Tight Closed Tight �. Reduced Pressure <br /> ` Initial Test By: Date: <br /> �. <br /> Repaired By: � Date: <br /> Final Test By:�� �j� �'������ Date:������� <br /> A183-0613 <br />