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Dolder Plumbing & Heating, LLC. <br /> f 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: " � • /J �`` ��j / <br /> % /� i�/ /� <br /> OWNERIOCCUPANT/CONTACT PERSON: / � �f /, ,�� CONTACT PHONE: <br /> <.0 i✓'� �w/:c�r/ <br /> DEVICE LOCATION: �� FLOOR#: � ROOM#: <br /> SERVES WHAT SYSTEM: / - <br /> � � 0 <br /> MAKE: MODEL#: SIZE: �� SERIAL#: C <br /> .�5�73/O <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONfiH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> 11'Z�-Z� /3 <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST �, O �, � S � <br /> 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(PLEASE PRINT FIRST&LAST NAME): <br /> -r-7� oJB/��v CERTIFICATION NUMBER: <br /> ll0 �' <br /> _ _ _ <br /> STATE OF MINNESOTA <br /> BAC;�FLOW kPZ TESTER UNLIMITED 'a±�sT�� <br /> �`,v��; �, <br /> Licc�nse# 061486-BF '"�.�� <br /> C'.. <br /> ExE;iration l�ate �. . V� �,� <br /> Ori�inal Issued Date 04/16/1998 �.�� �,�' <br /> ,�,�� <br /> R�BERT W DOLDER <br /> 404 6REEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />