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Pe-r n, I t --Pr PO 9q9 / <br /> REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT <br /> Service W4'jgontact _Name / `Lor0`V'i e +S ( h Person JCc Lod *�f <br /> Address a wd z /Ud W, Phone # 7990 <br /> 1< <br /> City, State Zip y� L� <br /> Account# Type <br /> Device Location <br /> Serial # 51'S S Type & Model Size _3 _ <br /> Install Date g (Overhaul Date 11 Test Date �-' E , G b <br /> Differential Pressure <br /> Check Valve #1 Check Valve #2 Relief Valve <br /> Annual Test 1. Leaked 1. Leaked Opened at <br /> psid reduced pressure. <br /> 2. Closed 2. Closed Did not open <br /> Cleaned Cleaned Cleaned <br /> Replaced Replaced Replaced <br /> O Disc Disc Disc Upper <br /> Spring Spring Disc Lower <br /> Guide Guide Spring <br /> Q Pin Retainer Pin Retainer Diaphragm Large <br /> Hinge Pin Hinge Pin _ _.Upper <br /> L- Seat Seat Lower <br /> W Diaphragm Diaphragm SEAT: <br /> Other Describe Below Other Describe Below Upper <br /> Lower <br /> Space, Lower <br /> Other Describe <br /> Final Test Closed Closed Lam- L,�, Open at Z, psid reduced <br /> pressure <br /> Sign and Date Tag on RPZ <br /> T above is certified to be correct <br /> Signed ', <br /> Date <br /> Mark'k Hanson <br /> Northland Mechanical Contractors, Inc. MarkA. -Hanson <br /> 9001 Science Center Drive Certificate# 01250T <br /> New Hope, MN 55428 License# 3957PM <br /> 763-544-5100 <br /> UAService Department Original betters-FOrmsviark Hanson RPZ letter.doc <br />