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Dolder Pl�umbing & Heating, LLC. <br /> �,,, 7760 County Road #26 Maple Plain, MN 55359 <br /> � -% Phone: 763-479-1942 Email: robdolder@aol.com <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: `��O � �� <br /> / <br /> OWNER/OCCUPANT/CONTACT PERSON: /�e � � CONTACT PHONE: <br /> DEVICE LOCATION:� C /�� FLOOR#: � ROOM#: <br /> ` SERVES WHAT SYSTEM: � �// �� `Q� <br /> /� <br /> MAKE: � MODEL#: o� SIZE: �� SERIAL#�: Z����D <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONfiH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> z-S- zo�� <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST � !� , � � <br /> / <br /> DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER <br /> OF THE DEVICE REMOVED): <br /> TEST DONE LEASE PRINT FI 8�LAST NAME): • <br /> � J CERTIFICATION NUMBER: <br /> __ ._ <br /> __ . _ ___ <br /> __ _ _ _ <br /> STATE OF MINNESOTA <br /> BAC;{FLOW ftPZ TESTER UNLIMITED Te+EsT <br /> ,�!� .. �,:: <br /> License# 061486-BF �� <br /> ... <br /> Expiration �)ate �. <br /> Orii inal Issued Date 04/16/1998 '�,"" � `' <br /> J ' ;�� <br /> �•iaid <br /> ROBERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />