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REDUCED PRESS�URE BACKFLOW PREVENTER TEST REPORT AND <br /> � � TESTABLE DOUBLE CHECKS <br /> Gl?� C�' 4QQN D Cont�ct PersonJTele M�� �pwr►1 �iSvZ• �73— 97a/ <br /> tddress: �.?.Tp �/:�G/� O . City: oF OQoN O Stat�; �t•/�/ zip: �;3�3 � <br /> �evlce Locatlon: ��u� �' � <br /> 21�0 FG. M�+� I�M, SgNe what systam: Q��� Wp� <br /> ►ccount Number; •• Sorial Number: alg'�a�. <br /> .ype' M�ko: WATTS Model: 6Qq . M Z <br /> nstt�ll Dato: Air Gap Install�tion Date �oNE " <br /> �abuild Date; Tast Date: <br /> �l���Q6 <br /> Annual �heck Valve�1 •� Check Valve#2 Differential Pressure Relief Valve <br /> Report ' <br /> Pre�sure g`4 pressure <br /> � Opened at a.a psid reduced pressure. <br /> Did not open <br /> Cleaned CleenecJ Cleanod <br /> Replacod Replaced Replacad <br /> R �� Oisc <br /> �! Disc <br /> E Disc, Uppor <br /> _, Spring Spring DiMc, Lowor <br /> P .�_ Guide Guide <br /> � Spring <br /> A �_ Pin Rec�iner Pin Retainer Dlaplvagm,Large <br /> � :_ Hingo Pln Minyo Pin Lower <br /> R �,^ Seat • • Seat Uppor <br /> Diaphragm Diaph�agm diaphragm, Small <br /> Othar,dasbribe Othor,describe Lower <br /> Upper <br /> SE:�I: <br /> Lower . <br /> ' Uppor � <br /> , Spacer, t,ower <br /> O�her,describo <br /> ..�] Sign and date Tafl <br /> rhe above Is certlfled correct. Sigrted � DateTested:`7�I_yC�06 <br /> I'estod by (Print Name) L�nn Gavi c Certiflc3lion Numb�r 0 0 4 4 2T <br /> Corporate Mechanical, Inc MN License Number 005363PM <br /> 5114 Hllisboro Ave N <br /> New Hope, MN 55426 <br /> (763) 533-3070 <br /> =ax (763) 533-3464 � <br /> DOO/U00 'd Sl �9l (3f11)9002-81-1f1f <br />