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. „ - z <br /> �=1�c� � <br /> Date <br /> WELD & SONS PLUMBING C0. <br /> 315 Juneau Lane <br /> Plymouth, MN 55447 <br /> . (763) 475-0296• Fax (612) 397-9370 <br /> - <br /> " APPLlCA't'�ON`FOR�BACKFLQW PREVEN70R TEST REPORT <br /> ...._—._. <br /> JOB ADDRESS�(BIDG A) (STREET NAME) (AVE•ST•BIVD�PKWY�ETC) (DIRECTiON N.E.S.W.N.E S.E; iBLDG NAME1 <br /> 7� s— o <br /> �� �i�i`i L_�� r��i�L S� <br /> OWNER/OCCUPANT: OESCHIPTION OF WORK: <br /> INSTALL �;ALTER � REPAIR `, REPIACE <br /> - ---- ---------- - -- --- — - - <br /> CONTACT PERSON: SERVE WHAT SYSTEM: <br /> -- �`rr,� �. �--, <br /> DEVICE LOCATION: FL R NUMBER:�ROOM NUMBER: <br /> ��1` 1 d-�' (' V�O �i I'_ _ _---- <br /> AKE: , • MODEL: SIZE: SERIALNUMBER� <br /> ���� ��;�,�s � �7s�� I `� /� - ���_ <br /> INSTALL DATE(MONTM,DAV d VEAR): OVERHAUL DATE(MONTN,OAV 8 YEAR): TEST DATE(MONTH,DAV 6 VEAR): <br /> r _, 5_ c 3 r �--..�—��3 <br /> CHECK VAWE CHECK VALVE PIiES.OIF.ACHOSS PRES.Dlf.WHEN S7RAiNER <br /> NUMBER 1 NUMBER 2 NUMBER 1 CMECK � REUEF OPENS <br /> TEST BEFORE I ❑ �AKED ❑ LEAKEO PS� �I . PSI �' �- NONE <br /> REPAIRS G' CLOSED ❑ CIQSED " CLND <br /> FINA�TEST i ��f GLOSEO �OSED � / PSI � �� � PSI ; ����. <br /> C <br /> DESCRIBE REPAIR: �/'�S��-I� � / �-s �-- �! _� _----_ -- <br /> ! C, / / <br /> ��r�i- i3��'� S�"%C'.z= -�---1� <br /> ESTIMATED COMPLETION TOTAL VALUE OF WORK: FEE: �CCI SURCHAFGE �,PERMIT FEE <br /> i <br /> �c+�r�L-o{v'_Lv�_'I i I I� � � s S S <br /> COMPA� . A � � . � LICA I N. <br /> /J, / <br /> � � � �G�h /G-�I��/��? AUTM.SI(iNATURE: '�i �yj <br /> L� <br /> OMPANY STREET ADDRESS: . <br /> �.�� � � <br /> �J[%��l LG�✓ �..l�1� <br /> CITY: . . . . , . <br /> / ���v� � .���� 7��_��s=c2�� � /�i� y�� <br />