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• <br /> Dolder Plumbing & Heating, LLC. <br /> "- , 7760 County Road #26 Maple Plain, MN 55359 <br /> Phone: 763-479-1942 Email: robdolder@aol.com <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: 3 / r/4 w.,,,'v,e 00 r <br /> OWNER/OCCUPANT/CONTACT PERSON: %c �� %re.- <br /> 0— <br /> DEVICE <br /> CONTACT PHONE: <br /> LOCATION: -l� ./�/i/eY ,/ 31 re55 _7 FLOOR#: / <br /> /� ROOM#: <br /> SERVES WHAT SYSTEM: /`� {/ Le � <br /> MAKE: &.i, / MODEL#: z ' SIZE: /7 SERIAL#: )7,2 el/5K 5 <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MOW-II/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> a- 20/0 //-i-2c2 <br /> #1 CHECK VALVE. RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST 7 6 /,„ 70 <br /> DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER <br /> OF THE DEVICE REMOVED): <br /> TEST DONE BY(PL S PRINT FI- NAME): <br /> ir, <br /> CERTIFICATION NUMBER: <br /> STATE QF MINNESOTA <br /> BACXFLOW RPZ TESTER UNLIMITED t'itfiyrq <br /> License# 061486-BF , <br /> Expiration nate ! <br /> Original Issued Date 04/16/1998 4,� y <br /> ROi3ERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />