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Feb 26 07 06: 23a Mar Borns Ce11#612) 685- ( 9521 937-9165 p. 2 <br /> REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT <br /> AND TESTABLE DOUBLE CHECKS <br /> • <br /> Service Name: "—all-- F I r Deft Contact Person/Tele ,"\ litt g Yo i-- Yl. <br /> / <br /> Address: 31-)0 IN i)IOw D . N. City: L-dllgL4k€ - State: Min Yl, Zip: w 65-35-0 <br /> Device Location: �l M ddey- 1O&YVl Serve what system:/ ,r�F�(' e -y-1A(-k "x )1 <br /> Account Number: Serial Number: D I'�- C I O 8 J <br /> I, <br /> Type: Make: Wa-H S Model: /c� (7S-RP Size: a <br /> Install Date: • n Air Gap Installation Date <br /> Rebuild Date: ell10 Test Date: -p( " O'/r� <br /> Check Valve #1 Check Valve #2 Differential Pressure Relief Valve <br /> Annual // p <br /> Report Pressure J, 6/ Pressure `7. Opened at •. osid recuced 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 /> rt <br /> Seat Seat UQper <br /> Diaphragm Diaphragm Diaphragm, Smail <br /> Other, describe Other,describe _ _ L y,,,er <br /> Uoper <br /> .eat: <br /> Lower <br /> Upper <br /> Spacer, Lower <br /> Other, describe <br /> i Sign and date Tag5� -,[ <br /> The above is certified correct. Signed OL DateTested: [C -0.7rz)9 <br /> Tested by (Print Name) /7/ b er La rs nA Certification Number 00 g,2'7 r- <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 />