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2012-05-1217:00 INTERSTATETESTING 7637555365» +952Z494616 pZ/Z <br /> Cross Connection Control Device PerfoRnanse Tsst <br /> Interstate Testin9 <br /> Z1d0144st Ave.NYV. <br /> Andover Mn. 66304 <br /> Phone(T83)7d4-6148 <br /> OYVNER INFORMAT <br /> O��r r, , �bwtllddMs <br /> �(Il N•�,-4,_ �Ol W r1 � h a <br /> b OwIN�'i�bMid PMson 7M�phnw Nur�b�r <br /> � � <br /> rFA�CN.�TY�IFOIiMATION <br /> �a 8restAddnds � r <br /> �- � � 9 ��-a' S 1 V! �'1 /� —"� <br /> � �Coa Ca�n4► <br /> O 6 � <br /> ��� <br /> _ .. _ <br /> CN ( � c..� � �} ? � �� �.� <br /> st� �y Ty� o,�oe��or o oc a oc n.a�or o PversvB , <br /> wn�u.�s�r <br /> � �� <br /> p Cb,ed tlpht �RP raYsi valva �L � PS�D <br /> U opsn <br /> StMic ' � PSID Sm� PSID Oid not .. <br /> •--------------------------•-----------------------------------------............................__..._...................._..---------•----------- <br /> EJIIAL <br /> OC1owa�ipn,t ❑Goaa apnc Operwa� PSIO <br /> Stalk PSIO � S�C PSID <br /> o�tECrat s�P�ss A3�tH1�.r iw'r�A6 t�t <br /> Q�� O�AOC�� RP rdMl alrs � <br /> ❑L6aksd [�L6oltod lJ Oid not open <br /> 94nk PSID S�lic PSIO <br /> ................................................................................----------------.............__..........................-----•---- <br /> DETEG?OR B1�PAS8 ASSEYBLY FN�41L TEST <br /> S4�c � PSIO Slidc � PSI� �°1�at P31D <br /> P�VAC'WMI�1lEAI�!N�1fAL TE'iT ; P�VA�CWM ellFJII�'R FINAL 1EST <br /> �iAk W�t whie �� <br /> �er�ed at PSID ❑�M ;�Opa�ed at PSIO O CbN�!dpht <br /> u de r+o�cpen O�.oleae � sfa�le PS�o <br /> . � PSIO ' <br /> COMMENT9 � <br /> � <br /> ��t�i�� yl q r` �-►�'4��te`�� <br /> � �U� ��-�ti-� � . <br /> .... .,_.. ._ ., �_ � <br /> I HEREBY CERT'IFY THE TEST RESULTS ARE TAUE ANO THE TEST WAS CONDl��C____BY I�AE PERSONAI.LY. <br /> Testa►Name(print) c:'�� I�'I.� f��e.s� Registralion No.D 6�3� �3�m+e d Oay <br /> � . <br /> r�er si�neturs o � .+-r� Phons No.76�, .. . oabe J J t �Z, <br /> '�t/C� (�,I�L�j <br />