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bolder 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`/d f, J/l A) pnv-e <br /> OWNER/OCCUPANT/CONTACT PERSON: , LA / e 777: CONTACT PHONE: <br /> P' <br /> DEVICE LOCATION: iv,Coz.e.( IJi FLOOR#: . �� ROOM#: <br /> SERVES WHAT SYSTEM: a//` C�� GL�� <br /> I.�/ /�C�? mac) f --CC����111 �>` Q.�5 <br /> MAKE: &h ,,, fizz MODEL#: /y (� g SIZE: SERIAL#: /l v33 <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH,/�'DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> /Z_'-/v //-/- Zoiz_ <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST • <br /> cv <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 /> r ' <br /> TEST DONE BY(PL PRINT AME): <br /> j. , CERTIFICATION NUMBER: <br /> STATE OF MINNESOTA <br /> BACXFLOW kPZ TESTER UNLIMITED °F xesT9 <br /> License# 061486-BF "`" <br /> Expiration Datebirct <br /> Original Issued Date 04/16/1998 �y� <br /> ROBERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />