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BACKFLOW PREVENTOR (RPZ) TEST REPORT <br />FLOOR #: ROOM #: <br />SERVES WHAT SYSTEM: <br />MAKE: MODEL #: SIZE: SERIAL #: <br />INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTH/DAY/YEAR): <br />(DO NOT PUT A FUTURE DATE IN THIS <br />BOX) <br />TEST DATE <br />(MONTH/DAY/YEAR): <br />CONTACT PHONE: <br />#1 CHECK VALVE <br />PSI/DIFF <br />RELIEF <br />PSI/DIFF <br />#2 CHECK VALVE <br />TEST BEFORE REPAIRS <br />FINAL TEST <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 />____________________________________________________________________________________________________________________ <br />JOB ADDRESS: <br />OWNER/OCCUPANT/CONTACT PERSON: <br />DEVICE LOCATION: <br /> <br /> <br /> <br /> James A. Duda CERTIFICATION NUMBER: <br /> 30726