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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 /GJ '-T y /J00 "(155-1 ‘ <br /> OWNER/OCCUPANT/CONTACT PERSON: / 6.CONTACT PHONE: <br /> DEVICE LOCATION: J ' P�ev FLOOR#: / ROOM#:-EA <br /> SERVES WHAT SYSTEM: <br /> MAKE: jC MODEL#: j / // / <br /> �� � ' SIZE: / h SERIAL#: 772 t 5 <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH/DAY/YEAR): GG TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> l�_ZGJ-Ld/3 <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST 777 /�' /- a C (G Cs <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(PLEASE <br /> PRINT FIRST&LAS ?N ME): <br /> CERTIFICATION NUMBER: <br /> STATE OF MINNESOTA <br /> BACKFLOW RPZ TESTER UNLIMITED �cFFsTa <br /> en <br /> License# 061486-BF <br /> Expiration Date <br /> Original Issued Date 04/16/1998 A. <br /> ROBERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />