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Dolder Plumbing & Heating, LLC. <br /> �„ 7760 County Road #26 Maple Plain, MN 55359 <br /> � -�% Phone: 763-47,9-1942 Email: robdolder@aol.com <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: �77� � � S �_ <br /> OWNER/OCCUPANT/CONTACT PERSON:/,� L��*C. �''CC CONTACT PHONE: <br /> GV r% <br /> DEVICE LOCATION: �� Z �' FLOOR#: �c�-- ROOM#: <br /> SERVES WHAT SYSTEM: O r O,,�R � �G� <br /> . <br /> MAKE: MODEL#: � SIZE: 3� SERIAL#: 9/���Z <br /> ��� if <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 /> /�-�= 20/ /- �a 2 <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF � PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST �v ��G�' �� <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 /> _ _. __._.. <br /> __ <br /> STATE OF MINNESOTA <br /> BAC±tFLOW RPZ TESTEYt UNLIMITED �ci�s�,,� <br /> :�.,.. _ <br /> �..� <br /> ;:�,`,.,,...,.,: . <br /> License# 061486-BF s; <br /> ExE;iration t�ate � <br /> Oriyinal Issued Date 04/16/1998 ���.y`��j. ��';� <br /> '"L'����ht"� <br /> ROk3ERT W DOLDER <br /> 404 6REEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />