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Feb 26 07 06. 23a Mar Borns Ce11#612) 685- ( 952) 937-9185 p. 2 <br /> REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT <br /> AND TESTABLE DOUBLE CHECKS <br /> Service Name: 1/ <br /> LO`� L k-e Pore 4'101-. Contact Person/Tele M t .,'e ig ire"u <br /> ! I-0111-4 <br /> . ....5_3_5_e, <br /> �2' �r l <br /> Address: '-1O \Nt\lo w ar. M . City: I-4Vlfs. 1.r� kg. State: itAYl Zip: - So <br /> Device Location: M ez Z4 VI t N e2 . Serve what system: Pc PSS 4 re et-C, L <br /> Account Number:• Serial Number:- 1 Li 6 . 3 3 <br /> Type: <br /> Make: Wto. tf S Model:069 1 , Size: 1" <br /> Install Date: o 3 Air Gap Installation Date <br /> Rebuild Date: \ ) Test Date: g"pl L'—67 <br /> Check Valve #1 Check Valve #2 Differential Pressure Relief Valve <br /> Annual <br /> Report V CP 1 <br /> Pressure a Pressure U • / Opened at ,1 osid recuced pressure. <br /> Did not open - <br /> Cleaned Cleaned Cleaned <br /> Replaced Replaced Replaced <br /> R Disc Disc Disc; Upper <br /> E Spring <br /> Spring _ Disc. Lower <br /> P Guide - Guide <br /> Soling <br /> A Pin Retainer Pin Retainer __ Diaphragm; Large <br /> I Hinge Pin Hinge Pin Lower <br /> p <br /> Seat Seat Upper <br /> Diaphragm Diaphragm Diaphragm, Small <br /> Other, describe Other, describe _ , oter <br /> Uoper <br /> Seat. <br /> . Lower <br /> Upper <br /> Spacer, Lower <br /> Other, describe <br /> i L/1/Sign and date Tag <br /> The above is certified correct. Signed_ �� 44-4,00`--44-4,00`----f oDateTested: g ' a /9-077 <br /> Tested by (Print Name) Alt)er-l- Q YS (SYS Certification Number 06q,TIT <br /> 'j <br /> Corporate Mechanical, Inc. <br /> 5114 Hillsboro Avenue North <br /> New Hope, MN 55428 <br /> Phone (763)533-3070 <br /> Fax (763)533-3464 <br />