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ouuEns � <br /> OWENS COMPANIES, �N�: BACKFLOW PREVENTER <br /> 930 East 80`h Street TEST REPORT <br /> Bloomington,MN 55420-1499 <br /> - 952-854-3800 Fax:952-854-3769 <br /> i" '� <br /> i � www.owensco.com �('�S F��„1 k-T� �tx��-rr'�a� <br /> Locally Owned- Nationally Recognized- Since 1957 <br /> Work Order Number: � Date: \ <br /> Name: � � �� ` �� Home Phone: <br /> Address: � � Work Phone: <br /> Ci , State,Zi : � (� '� Cell Phone: <br /> Location of service if different: �' 6 � � Email: <br /> Make and Model of Device: Size: � '' Serial No.: L.� ( , <br /> Check Valve#1 Check Valve#2 Pressure Differential Pressure Differentiai Strainer <br /> , �` Across#1 when Relief Opens <br /> Test Befo�e Leaked ❑ Leaked ❑ � None ❑ <br /> Repair P.S.I. P.S.I. <br /> Closed ❑ Closed ❑ Cleaned ❑ <br /> Describe ����� r�U�� �� <br /> Repair: <br /> Leaked ❑ Leaked ' ❑ <br /> Final Test r�' �� P.S.I. � � P.S.I. <br /> Closed ❑ Closed ❑ ��` 1...-' `--� <br /> Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: <br /> Replaced: ❑ Replaced: ❑ Replaced: ❑ <br /> CDisc ❑ Disc ❑ Disc: ❑ <br /> � <br /> �- Spring ❑ Spring ❑ Upper ❑ <br /> Guide ❑ Guide ❑ Lower ❑ <br /> Pin Retainer ❑ Pin Retainer ❑ Spring ❑ <br /> 'o Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ <br /> d <br /> E <br /> � Seat ❑ Seat I ❑ Large: ❑ <br /> m <br /> a � <br /> ` Diaphragm Diaphragr� Upper <br /> °' ❑ ❑ Lower ❑ <br /> m <br /> � <br /> ❑ �_❑ Small ❑ <br /> ❑ �_❑ Seat: ❑ <br /> ❑ I� ❑ Upper ❑ <br /> ❑ �❑ Lower ❑ <br /> ❑ �_❑ Spacer: ❑ <br /> � � Lower ❑ <br /> Final Test I Opened a _Ibs <br /> Closed Tight � Closed Tigh4 Reduced Pressure <br /> � Initial Test By: Date: <br /> Repaired By: � Date: <br /> Final Test By:�`�� \--�(��'� ���v���� Dat��,"�G�"1 <br /> A183-0613 I <br />