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CITY OF MINNEAPOLIS,REGULATORY SERVICES <br /> INSPECTIONS DIVISION <br /> _ 250 South 0 Street-Room 300 <br /> / Minneapolis,MN 55415-1316 <br /> www.el.min neapolls.mn.us/onestop <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: -3 �s <br /> v <br /> OLVMER/OCCUPANTICONTACT PERSON: ��, 1� 1 CONTACT PHONE ?-? <br /> Ci^ n <br /> DEVICE LOCATION: Watt &00 FLOOR#: TROOM M <br /> SERVES WHAT SYSTEM: <br /> MAKE: �,/ MODEL#: c/-7 5-(, SIZE: SERIAL#: (1 � <br /> INSTALL DATE(MONTHIDAYIYEAR): OVERHAUL DATE(MONTH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSUDIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST -7. <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&LAST NAME): <br /> CERTIFICATION NUMBER: jj a <br /> COMPANY NAME: OL G ( m ( co CONTRACTOR LICENSE#: 5:3 42 rM <br /> COMPANY ADDRESS: ( -01 COMPANY PHONE M ♦( -31 <br /> CITY: �C .E STATE: (11 t'►! ZIP.55anl CONTACT PERSON/PHONE#: r G <br /> ATTACH THIS COMPLETED TEST REPORT TO PLUMB[NG/GASFITTING/RPZ PERMIT APPLICATION AND <br /> SUBMIT WITH FEE. <br /> 1/19/2006 <br /> f _ . <br />