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\` <br /> Dolder Plumbing & 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: z��� . ✓� �-,;� ,s��� �J <br /> � l�•� U <br /> OWNER/OCCUPANT/CONTACT PERSON: ' , CONTACT PHONE: <br /> / C <br /> DEVICE LOCATION: ��ZZ���h,� FLOOR#: � ROOM#: <br /> ' SERVES WHAT SYSTEM: ��5 ` � G / � <br /> /�" / <br /> MAKE: /'.) MODEL#: �,y�� SIZE: � SERIAL#: ��f y�, <br /> (�� /�� <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MON�'H/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> /�'�'�O� (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> l��"X/Z <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST �j � � �j�� � o <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 BY(PLEASE PRINT FIRST 8 LAST NAME): <br /> � CERTIFICATION NUMBER: <br /> ___..__ <br /> _ __ <br /> STATE OF MINNESOTA <br /> BAC�{FLOW RPZ TE5TER UNLIMITED �itEsy,�>� <br /> '��;:. �, <br /> Licc�nse# 061486-BF � -��i. <br /> ExF;iration i)ate <br /> Oric mal Iss.ied Date 04/16/1998 � �� -.` <br /> � �.'�+`�. <br /> ROt3ERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />