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MAY. 27. 2008 7: 36AM LBP. MECHANICAL � N0, 065 P. 3 <br /> , I �17Y pF MINNEAPOUS,R�GUI.AT�RY S�RVICES <br /> � tNSpECT10NS DIVISION <br /> ; 250 South 4u'Street-Raom 3� <br /> iMi�neapolis,MN 55415-1316 <br /> www�d.minneaoolis.mn.ush�tdr <br /> BACKFLOW PREV�NTOR (RPZ) `TEST REPORT <br /> �os n�oR�ss: � 6 . <br /> bWNER/bCCUPMRlCOM'ACT PER�ON:� � CONTACT PHfJN�: <br /> �� <br /> DEVICE LOCATION: � � " F�OOR� ROOM� <br /> SERVES YVH/1TSYST'EIIM: ' ,Q <br /> .�� <br /> ,�: Moo��; 96 � �: � �, sEwa.�: � <br /> INSTALL DATE(MONTFUDAYlYFAfi�; OVERHAUI.DA?E(MONTHIDAYlYFAR): T�ST DATE(MONTFUpAY/YEAR): <br /> (p0 NOT p A FUTURE OATE W THI�BO� <br /> � �� o � � � <br /> �1 CHECK VALVE REIJ�F �2 CHECK VALYE <br /> PSUD F ' <br /> 7�ST BEFORE REPAIRS <br /> • �INALTEST �� Gt�.�'D ? Q �i�, �%�+� <br /> n�SCRl9�R�PAIR IP ANY{IF 7HIS IS A NE1N 1NSTALLqTl01d AND REPLACES AN'EXIS71yG DEVICE.INDICATE 7HE SERIAL NUMBER <br /> oF ni�a�l.�e�ss�� <br /> TEST DONE BY(PLEASE PRINT FlRST 8.U►ST WWE): <br /> ' C�eRTiflCA1'ION NUN�ER; <br /> G � �` <br /> coMP ��: P �' ��s cx��+rnac�roR ucase�a <br /> CO�APAIiY A RESS: O • iG ' CONPANI(PHONB alk ^ 3.�^ <br /> CITY: 3TA ' ZIP: ' CONTA�'I'PERS� ki� <br /> A1'TACN Y'HIS COMPLETED TEST REPORT T PLUMBING/GASFI'�TIN(3/Rpt PERNIT APPLICATION AND <br /> SUBMI'F WITH F�:E <br /> 7/30/2007 <br />