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, <br /> (r'-; '' T_.P Svx 44za' ayti .'i' 3c ..+1:i^1'. <br /> t - -[ech nlc l contra t® 9 inc <br /> . ,,, r1e,_3. ''. _..,. . s,- -:,:-v.„;„,t�t. : _" °rK-- .'_tom ?-�"_-- .' <br /> COMPLETE JOB ADDRESS(INCLUDE Apt/Unit#) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER <br /> e7 / , , • <br /> APPLICANT COMPANY NAME CONTRACTOR LICENSE# CONTACT NAME AND PHONE NUMBER <br /> Associated Mechanical Contractors, Inc. L098 22749 Kevin Manske 952-233-3106 <br /> ADDRESS CITY STATE ZIP EMAIL <br /> PO Box 237 Shakopee MN 55379 kmanske@associatedmechanical.colr <br /> TESTER NAMETESTER CE.TIFICATION# PHONE <br /> Se &- /e .6- is 952-445-5100 <br /> BACKFLOW ASSEMBLY DETAIL INFORMATION <br /> Type(check one): Reduce Pressure Principal or Pressure Principal Fire Protection _ Reduced Pressure Detector Fire Protection <br /> _Doubt K <br /> ck Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker_Spill Resistant Pressure Vacuum Breaker <br /> Manufacturer: tz.2,'4c, -"/./...5, Model# ? -- X 2-., Serial#/3 /4.11.72.,/ <br /> 3.6�� ,,I 1/yam,(,ize: 'VI/ (inches) <br /> System Serviced G'/Jer 4^/// Location in bldg /57 /�,�T�C pt e'/'z'' Ioor#/ Room# <br /> TEST RESULTS: _._ass Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) <br /> Reduced Pressure Principal or Reduced Pressure Detector Fire Protection(RP)—TEST RESULTS <br /> Check Valve#2 I Shutoff Valve#2 Check Valve#1 Pressure Differential <br /> Relief Valve <br /> Initial Closed Tight ,-Yes No Closed Tight Yes No Closed Tight Yes_No <br /> id 3 <br /> Test Opened at psid <br /> Pressure Drop Across Check Valve#1� ps <br /> Final Closed Tight Yes No Closed Tight Yes No Closed Tight _Yes_No Opened at psid <br /> Test Pressure Drop Across Check Valve#1 psid <br /> Double Check Valve or Double Check Detector Fire Protection(DC)—TEST RESULTS <br /> Check Valve#1 Check Valve#2 I Shutoff Valve#2 <br /> Initial Test Closed Tight _Yes _No psid Closed Tight Yes No psid Closed Tight _Yes _No <br /> Final Test Closed Tight _Yes No psid Closed Tight _Yes _No psid Closed Tight _Yes No <br /> Pressure Vacuum Breaker(PVB)or Spill Resistant Vacuum Breaker(SRVB)—TEST RESULTS <br /> Air Inlet Valve Check Valve Shutoff#2 <br /> Failed to Open _Yes _No Closed Tight Yes No <br /> Initial Test -- — Closed Tight Yes _ No <br /> Opened at psid Pressure Drop Across Check Valve#1 psid Final Test Opened at Closed Tight _Yes _No <br /> p psid Pressure Drop Across Check Valve#1 psid Closed Tight _Yes_ No <br /> Describe parts and repairs when needed: <br /> CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that tr e .ested device is functioning in compliance with <br /> State of Minnesota Plumbing Code,Chapter 4714. <br /> TESTER'S SIGNATURE _....§0111111b '- TEST DATE: •-2 7'/ A.- <br />