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REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT OR <br />TESTABLE DOUBLE CHECKS <br />Service Name: Contact Person/Tele: <br />p <br />Address: 7y ��C%� is City: <br />State: <br />Device Location: Serve what system. <br />Account No: Serial Number: <br />Type: �/�� <br />Make: /I/'' �' Model: t2 Size: c;� <br />m <br />Rebuild Due Date: <br />Annual <br />Report <br />Test Due Date: <br />Check Valve #1 Check Valve #2 �� �" Differential Pressure Reiiet valve <br />Pressure v' Pressure T� Opened at psid reduced pressure. <br />Did not open 1.2 <br />Cleaned <br />Cleaned <br />Replaced <br />Replaced <br />R Disc <br />Disc <br />E Spring <br />Spring <br />P Guide <br />Guide <br />A Pin Retainer <br />Pin Retainer <br />I Hinge Pin <br />Hinge Pin <br />R Seat <br />Seat <br />S _ Diaphragm <br />Diaphragm <br />Other, describe <br />Other, describe <br />t_(] Sign and date Tag <br />The above is certified correct. Signed <br />Tested by (Print Name) <br />Todd Maul <br />Cleaned <br />Replaced <br />Disc <br />Spring <br />Guide <br />Diaphragm, Large <br />Lower <br />Upper <br />Diaphragm, Small <br />Lower <br />Upper <br />Spacer, Lower <br />Other, describe <br />DateTested <br />f^� <br />Certification Number 067999BF <br />201 10001591 <br />Company Name: Cities I Plumbing and Heating Inc <br />License Number <br />Company Telephone Number 651-274-6547 <br />All sections of this report must be completed. <br />Return to: Saint Paul Regional Water Services Fee per Device <br />ATTN: Mollie —Engineering $ 35 <br />1900 Rice St <br />Saint Paul, MN 55113 <br />Fax: 651-266-6287 <br />E-Mail: Water-PlumbingPermitApp@ci.stpaul.mn.us <br />*$35.00 testing fee will be applied to customer's water bill <br />