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ouuEns ' <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 �(�!(�L <br /> - Local/y Owned- Nationally Recognized- Since 1957 <br /> Work Order Number: Date: � <br /> Name: `' � `. Home Phone: <br /> Address: � <sU [� Work Phone: <br /> Cif , State,Zi : A Q�' �"�' \ Cell Phone: <br /> Location of service if different: . }4-cw--��e2.�a� Email: <br /> Make and Model of Device: i�./� "'�� Size: Serial No.: � <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 /> Des�cribe ��� � �j��U�� G-�7'"�„ <br /> Re air: �, ��� <br /> Leaked ❑ Leaked ' ❑ .�,. , {�� <br /> Final Test ❑ � f � 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 /> � � S rin ❑ <br /> �--- p g ❑ Spring ❑ Upper <br /> Guide ❑ Guide ❑ Lower ❑ <br /> Pin Retainer ❑ Pin RetainQr ❑ Spring ❑ <br /> � Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ <br /> m <br /> E ❑ <br /> � Seat ❑ Seati ❑ Large: <br /> m <br /> a � <br /> ` Diaphragm Diaphragr� Upper <br /> °' ❑ ❑ Lower ❑ <br /> � <br /> ❑ �❑ Small ❑ <br /> ❑ �❑ Seat: ❑ <br /> ❑ �_❑ Upper ❑ <br /> ❑ �❑ Lower ❑ <br /> ❑ �❑ Spacer: ❑ <br /> ❑ ❑ Lower 0 <br /> ---�, <br /> ° Opened a ' Ibs <br /> Final Test Closed Tight � Closed Tigt�t ` — <br /> Reduced Pressure <br /> ( � Initial Test By: Date: <br /> � <br /> Repaired By: Date: <br /> FinalTestBy: 1c_ �C. �--;11�' �� �t��� Date: ��--; (�"�1� <br /> A183-0613 ' I <br />