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Ryan Companies US, Inc <br /> 50 South Tenth Street, Suite 300 <br /> Minneapolis, MN 55403 <br /> 612-492-4953 David Mollen Report oil Test and Maintenance <br /> of Back ovy Prevention Device <br /> Please use a separate form for each device. For the year_ <br /> Initial test- Complete entire form <br /> Annual test-Complete Par!A only <br /> Public Water Supply Account No. Count <br /> Y - Blork Lot <br /> /FaciliNamLocation of Device <br /> ty es I 'f �, <br /> Address 11 ��. P �1 <br /> -55" � <br /> Street City Zip <br /> Device Manufactur r <br /> Information Type PZ_ M el Si e(in,inches) Serial Number �) <br /> L /_ �JCV Y /V <br /> Check Valve No.1 Check Valve No.2 Differential Pressure elief Line Pressure (� <br /> psi <br /> Valve <br /> Test Leaked B Leaked 0 Opened atsid Date <br /> ht <br /> g Closed <br /> before Closed tiP I <br /> tight O l—1 —� m � 1 <br /> repair l J <br /> Pressure drop across first check valve <br /> psid M D Y <br /> Describe <br /> repairs and Repaired by <br /> materials Name_ _ <br /> used <br /> Lic# <br /> Date repaired. <br /> i <br /> M D Y <br /> Final test Closed tight Closed tight Opened at Date <br /> P psid <br /> fx <br /> Pressure dr oss first D tY[ <br /> check valve psid <br /> Water Meter Number Meter Reading Type of Service (check one) <br /> ❑Domestic ❑ Fire NQ1_ Otherk�� <br /> Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc.) <br /> C I I tion'This device meets, 11 does NOT <br /> /m}�eett,,the requirements of an septa le c t vice at the time of testing <br /> �%r hereby �tif✓tp���///for�oing data to be cot /v ✓ L <br /> Print Name �'r(/J Z`C /`-- Certified Tesler No. Ignature / /-- <br /> Expiratiun Dale <br /> Property owner's(or owner's agent)certification that test was performed <br /> 1 G tis \/f/�11t �In <br /> Pri IName ITiI 1 I i/ I��--�:C"�y�'t �� _'!�_ � <br /> SY <br /> Signature Telephone <br /> Certification that Installation Is in accordance with the approved plans. (To be completed by the design engineer or architect or water <br /> supplier.) <br /> I hereby certify-that this installation is in accordance with the approved plans. — <br /> Name Title Date NYS DOH Log# <br /> License Number Phone( ) m d y — -- <br /> Representing Describe minor installation changes <br /> Address <br /> State Zip <br /> iSini-I?iu re <br /> _-_ <br /> I Sunt or omoleteG cnnv it, <br /> • ,�, r� �i wait-�Jp,o I(`I II`.i..J,u,vi uEvuc rte:= v daof e"IC fa lis Idsi d,u repair§carinoLIrnnledlarely be made. —.— <br /> U01-1-1013(9191) <br />