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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 ovv Prevention Device <br /> Please use a separate form for each device. For the year_ <br /> Initial test- Complete entire form <br /> Annual test-Complete Parf A only <br /> Public Water Supply Account No. County Blork <br /> / Lot <br /> [� � Location of Device <br /> Facility N))am <br /> Addres67C4L-11i iI4r`v Ow <br /> Street City Zip <br /> Device Manufacturer TypeAli <br /> PZ Model Size(in inches) Serial Number <br /> nformation ` �CV L 3 <br /> Check Valve No 1 Check Valve No.2 Differential Pressure Relief Line Pressure <br /> Valve psi <br /> Test LeakedB Leaked Opened at psid <br /> repair Date <br /> before I <br /> Closed tight Closed tight <br /> Pressure drop across first check valve <br /> psid <br /> M D Y <br /> Describe ——'– --- <br /> repairs and Repaired by <br /> materials Name_ <br /> used <br /> Lic# <br /> Date repaired. <br /> M D Y <br /> Final lest Closed tight <br /> 9 � Closed tight Date Opened G psid � � /���/�� <br /> Pressure drop cr s first 'M I p F12 IJ I <br /> check valve psid <br /> Water Meter Number Meter Reading Type of Service_(check one) <br /> Domestic ❑ Fire Other— <br /> Remarks(Describe deficiencies.bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc) <br /> Certification This device meets, L does NOT meet,the requirements of an ac ptab e con inme t ice at the time of testing <br /> I her b rtify f gin data to be correct �t <br /> Print Name lb- 7 <br /> Certified Td Tees�tter✓✓✓,No_. Signature Expiration Dale / <br /> Property o finer' (or owner's agent)certification that test was performed: <br /> iA4oVQ 0�d <br /> Pri Name Title Si nature <br /> 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 c rtify that this installation is in accordance with the approved plans. — — <br /> Name Title Date NYS DOH Loy M <br /> License Number Phone( ) m d y <br /> Representing Describe minor installation changes <br /> Address I I <br /> Ciy _ State Zip <br /> i Sid rl'n iU fr_ � I <br /> •,l,_1 c.Sena on comoietetl-, ,a n _ - ..;, •.-c.;d: ra,a, -rF,,�, ..o�days o:%r—ting devic�— ---- <br /> dp�; <br /> and M crc"oup��IC` II'.....J�o..;�� �evi�c iaie�2a�a,,U Iepalrs cannot rr lrrledlaten,be made. L)01­1-1013(91191) <br />