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Feb 26 07 06: 23a Mar Borns Ce11#6121 685- (9521 937-9165 p. 2 <br /> REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT <br /> AND TESTABLE DOUBLE CHECKS <br /> Service Name: <br /> LCSYI Lake rete Deft, Contact Person/Tele M. I t\t' •gYOLU IN- <br /> 1- � <br /> Address: 31 ►N , t)W Of. kl , City: L-0^1. L4It. State: ,.1 n_ Zip: 55354 <br /> Device Location: Q+t'c I4\e ker KOOYYl Serve what system: I-a.wyy\ .�ri�A�t-" l 0A <br /> Account Number: Serial Number: g '7 a 118'5 <br /> ,,�_ U/ 1�a,, <br /> Type: <br /> Make: re loco Model: _ � Size: <br /> Install Date: o'3 Air Gap Installation Date L <br /> Rebuild Date: 1 0 Test Date: 39- ( ^6 7 <br /> Check Valve #1 Check Valve #2 Differential Pressure Relief Vaive <br /> Annual <br /> Report4 77 <br /> Pressure 7. Pressure 6, ( Opened at J. a osid recused pressure. <br /> Did not open - <br /> Cleaned Cleaned Cleaned <br /> Replaced Replaced Replaced <br /> R Disc Disc _ Disc; Upper <br /> E Spring Spring _ Disc, Lower <br /> P Guide Guide Spring <br /> A Pin Retainer Pin Retainer __ Diaphragm, Large <br /> 1 Hinge Pin Hinge Pin Lower <br /> R <br /> Seat Seat Upper <br /> Diaohraom Diaphragm Diaphragm, Small <br /> Other, describe Other,describe __- , yver <br /> — <br /> (Japer <br /> Seat: <br /> • Lower <br /> Upper <br /> Spacer, Lower <br /> Other, describe <br /> — <br /> i Sign and date Tag <br /> The above is certified correct. Signed 1/i C, /4,v DateTested: 31-07 L( '",V <br /> Tested by (Print Name) /7/he e`,_ 1 1- a lrs. D Certification Number (1.709o7i)7*-- <br /> . <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 />