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� r�EDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT AND <br /> � . � TESTABLE DOUBLE CHECKS <br /> 3er' � Name: C1'� d''F 4�N � ' Contact Person/Tole /�•/j� . <br /> addr�ss: sH���•(!£ O , �pt,�J�J 9� ��-�?70T <br /> 3770 O�¢o�MM c��y:�1i��.QE state: �y�� zlp: r,�3a3 . <br /> �evlce �ocation�� �`. M� Serve.what system: ��� ''j��� <br /> Q� F�w <br /> account Number: �� Serlal Number: eis"J3qp <br /> rype. Make: WATTS Model: cT� �°� <br /> nstt�ll Dale: �,ir Gap Inst�llation Dete ' <br /> Rebuild D�te: 7est Date: <br /> � ��/ /o G <br /> Annual Chock Valve#1 •� Chock Valve#2 pifferenti&I Pre�sure Reliof Valve <br /> Report ' . <br /> Pressure �_ .°� Pressure <br /> � Opened at a.9 usid reduced pressure. <br /> . Did not open <br /> .�_ Cleaned `�, Cleaned Cleanod <br /> ��, Replsced Replacod Ro(�laced <br /> R ,"__ Di�c <br /> Olsc <br /> � _, 5prin S rin Disc, Upper <br /> P �, Guld� Guida Disc, Lowar <br /> q � Spring <br /> `_ Pin Rotainer Pln Ratainer Olapl�rdpm, Large <br /> � �: Hinge Pln Hin9e Pin <br /> Lower <br /> R :,,., Seat Saat Upper <br /> ,..�,� Dlaphragm Diaphr:�gm Diaphragm, Sm�ll <br /> �_ Othar,descr(be _.� Other, doscribe LOwot <br /> Up�er <br /> Seat: <br /> lowor <br /> . , Upper <br /> . Spacer, Lower . <br /> .�+ Other, doscribe <br /> -� 1 Sign and date Tag <br /> the above la cerlified carrect. Signecl � / <br /> DateTested:r? l��f L 06 <br /> Pested by(p�jnt Name) Lenn Gavic <br /> CertiFlcation N umber 0 0 4 4 2'� <br /> Corporate Mechanical, Inc <br /> 5114 Hillsl�oro Ave N MN License Number 005363PM <br /> New Hope, MN 55428 <br /> ;763) 533�3070 <br /> =ax (763) 533-34G4 � � <br /> D00IE00 'd Sl �9l (3f11)9002-81-1f1f <br />