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����� REV TER <br /> OWENS COMPANIES, �N�. BACKFLOW P EN <br /> 930 East 80t"Street TEST REPORT <br /> Bloomington,MN 55420-1499 <br /> ;,� 952-854-3800 Fax:952-854-3769 <br /> � �� www.owensco.com �L� <br /> � Locally Owned- Nationally Recognized- Since 1957 <br /> Work Order Number: Date: �" � ° � � <br /> Name: � � �c�'�i��Y.�� Home Phone: <br /> Address: ��� � � �'� ' Work Phone: <br /> Cit ,State,Zi : ��, , , �, } Cell Phone: <br /> Location of service if different: •� ��. -�p� ., mail: <br /> Make and Model of Device: \ � � Size: t -�°' Serial No.: <br /> , � <br /> �} Check Valve#1 Check Valve#2 Pressure Differential Pressure Differential Strainer <br /> � Across#1 when Relief Opens <br /> Test Before Leaked ❑ Leaked ❑ None ❑ <br /> Repair P.S.I. P.S.I. <br /> Closed ❑ Closed ❑ Cleaned ❑ <br /> Describe �„T,�_ � �� `�l��J ����� <br /> Repair. '—�y +��;�v U <br /> Leaked ❑ Leaked ❑ �� '�"� <br /> Final Test �,� P.S.I. / � P.S.I. <br /> Closed ❑ Closed ❑ �`� <br /> Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: <br /> Replaced: ❑ Replaced: ❑ Replaced: ❑ <br /> Disc ❑ Disc ❑ Disc: ❑ <br /> r ) ❑�'�__-�" Spring ❑ Spring ❑ Upper <br /> Guide ❑ Guide ❑ Lower ❑ <br /> • Pin Retainer ❑ Pin Retainer ❑ Spring ❑ <br /> � Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ <br /> ,t Seat ❑ Seat II ❑ Large: ❑ <br /> m ❑ <br /> °' ❑ Upper <br /> ` Diaphragm ❑ Diaphragm <br /> d ❑ ❑ Lower ❑ <br /> � <br /> ❑ �❑ Small ❑ <br /> ❑ �❑ Seat: ❑ <br /> ❑ �I ❑ Upper ❑ <br /> ❑ I ❑ Lower ❑ <br /> ❑ �❑ Spacer: ❑ <br /> � �� Lower ❑ <br /> � <br /> ' Opene Ibs <br /> Final Test Closed Tight Closed Tight I <br /> � Reduced Pressure <br /> (, ) Initial Test By: I Date: <br /> `�, <br /> Repaired By: , Date: <br /> Final Test By� \�� �c o7 l��i". s� ``=�'7����`v Date: �-�" L" ���` <br /> `=V <br /> A183-0613 <br />