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Dolder 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: � '"'� �• � �a zG� �� ) �^�� / <br /> / !r/ Z.J J � <br /> OWNER/OCCUPANT/CONTACT PERSON: /� C,E�l� /``v Q s/.���LZ CONTACT PHONE: <br /> Go rt� <br /> DEVICE LOCATION: • FLOOR#: ROOM#: ' <br /> SERVES WHAT SYSTEM: �/� //C L�� <br /> � /l/ 6 <br /> MAKE: /, � MODEL#: O� m SIZE: 3/ SERIAL#: �� <br /> lN <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 /> ����9 Zo �3 <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST �J' , z s /'1 /, O <br /> t� / C! �O <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 8 LAST NAME): ' <br /> � / CERTIFICATION NUMBER: <br /> l P✓ <br /> _ <br /> __ <br /> STATE OF MINNESOTA <br /> BAC�CFLOi! RPZ TESTER UNLIMITED �x�s <br /> ���, � <br /> Gi, <br /> Licc�nse# 061486-BF �e�: <br /> Expiration l�ate �.. . V� �,�,' <br /> Ori�inal Issued Date 04/16/1998 �.���� <br /> RQt3ERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />