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P&II SERVICES CO., INC. <br /> PLUMBING *HEATING & PIPING <br /> 1601—67'Avenue North•Minneapolis,MN 55430-1743 <br /> Office:763-560-1080 t Fax:763-560-0164 <br /> Backflow Preventer Test Report <br /> Instructions to Certified Testers: All information must be typed or clearly printed in black ink. <br /> Site Addres•� Z3 z„ 4' <br /> , A r <br /> City: Zip Code: <br /> Occupant: Telephone: Test Date: <br /> —129 � ( <br /> J*/ two 1 �5 ,j > •7 o'1 <br /> Device Ma Size: Serial No. <br /> AIV4(le A4.-5/ a/Ott <br /> Device Model: I�� i > 9 <br /> Test Period: Overhau •tall 1st Yr 2nd Yr 3rd Yr 4th Yr <br /> (Circle One) <br /> ` <br /> • <br /> Device Location: <br /> d&Y12liiDevice Serves Wystem: <br /> PRES DIF CHECK PRES DIF <br /> ACROSS VALVE WHEN RELIEF STRAINER <br /> # 1 CHECK #2 OPENS • <br /> Test Before None " <br /> Repairs psi Closed ( ) psi <br /> Final CLND ( ) <br /> Test psi Closed psi <br /> Describe Repair if any: <br /> V4 f444- <br /> If this is a new installation and replaces an existing device, <br /> Indicate the serial number of the device removed. <br /> CERTIFICATION: <br /> I hereby certify the following data to be correct and that the tested devise is functioning within the limits <br /> of the standards. / <br /> � � . / / `W <br /> Certifie V.%f'. :AO/�. _ .d / _ Certification e=5��`1 <br /> ignature) <br />