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i <br /> MAY, 21. 2008 7; 31AM LBP. MECHANICAL N0, 065 P. 5 <br /> CIN OF MINNEAPOLI8,R@GULATbRY S�RVIC�S <br /> , INSI�EC7'IONS DIVISION <br /> 250 Sotrth 4�'S'a+aet—Room 800 <br /> ; dAinnaapofis.MN 55diS-1316 <br /> I <br /> , www.ci.minnoaooli�mn.us/mdr , <br /> E3ACKFLb18V PREVEf�`TOR (RP�) TEST REPORT <br /> Joe AOD�ss: �s OO ��� <br /> OWNER/OCCIiPANYICONTACT PERSON: �°'�,�� CONTACT PHONE: ��3� /�9 3 <br /> DEVICE LOC/ITION: f� � FL'OOR� l d ��' ' �: <br /> $ERVES WHAT 3YSTEM: �J � � ^ O �U.� <br /> w�: � Mooa�: g� � s�: � sEw��: y�3 Z 4/ <br /> INSTALL DA7E(INONTHIDAYlYEAR�; OVERNAUL DA'i'�(MONTN/DAY/YEAR): 7�ST DATE(MONTHIDAYlYEAI�: <br /> (DO NOT PUT A FU111RE DATE W THIS BOX) <br /> d,� 0 S� s �/ Q 8 <br /> �k1 CHEq(WALVE Ii�UEF �A1�1C VALVE <br /> pSUpIFF PSIIDIFF <br /> 'I�ST B�FQRE REPAIRS <br /> � ���sT �,o f�,p �'..a .a.d2 ��sa <br /> DESCRIBE REPAIR IF ANY(IF i'WIS 1S A NEW 1NSTALLATNON AND REPLACES AN E�qS11MG DEVIC�,INDICA'TE 7HE SERUI�NUMBER <br /> OF THE DEVICE REMWED: <br /> d -- � .� .��,.�.�,�- <br /> TEST OQNE B1f(PLEAS@ PRINT PIR�T 8.LAST NAMq: � <br /> ' ' C�R7'II�ICATiON NUMBER: <br /> e � ' - . <br /> 3 <br /> ca�►aMr��: La e N � r.�� MPLS CONTRACTOR UCLNB�� <br /> ANY 14dDF1ESS: / �O� �' C Y PFiONE Ik �3 3 y h�1 <br /> GTY: �8 ATE: ZIP: CO ACT IP O �#: <br /> � ATTACH THIS�OMAPf.ETED T�ST REPORT T PI.UMBING/OASFITTINC,JRPZ PERMIT APPUCATION AND <br /> SUBMIT WJTH F�� <br /> ��sa2oo� <br />