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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: V!1 a),. - PA,fe L� ,74/ <br /> OWNER/OCCUPANT/CONTACT PERSON: ;4 <br /> 1 CONTACT PHONE: <br /> do r 11 <br /> ire <br /> DEVICE LOCATION: FLOOR#: ROOM#: <br /> SERVES WHAT SYSTEM: 6-44 <br /> Gy� - <br /> MAKE: /.)eat, MODEL#: SIZE: // SERIAL#: /��6 3? <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 /> /2-29-2420 <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST F 1 2 0 <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(PLEA E PRINT FIRST&LAST NAME): <br /> CERTIFICATION NUMBER: <br /> STATE OF MINNESOTA <br /> BAC FLOW RPZ TESTER UNLIMITED Fsrti� <br /> License# 061486-BF AL4‘144 <br /> Expiration mate !� <br /> Original Issued Date 04/16/1998 <br /> RO3ERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />