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M • � y. <br /> ' � <br /> � 7625 Boonc AVenue North <br /> � � $rooklYn Parlc,MN 55428 <br /> � ���� ��� Ma3n'763.544-4131 <br /> � Fa�t 763.S95.h346 <br /> Ax►Egan�ompaa�r www.eganca.co»i <br /> BACKFLOW�PI�EVENTFi� TEST RFP�R.T <br /> Instruction5 t0 Certified 7esters: All information must be T ed 4r ciearl linted in b1aCk Ink <br /> S17E ADDI��SS: � 7� !(/ � /� � m /`� ��o`[��� �6(. ZIP: � <br /> OCCUPANT: /`Y�r� � ���'1 ✓�'`ff PH�NE: TEST OATE: �r'�`�� <br /> DEVICE MAK�/MOD�L: .f � <br /> SIZE: t� SEAIAL NO_ l � ��/ <br /> .. �� . <br /> DEVICE l,4CATiON: .2. �=��-� � <br /> SYSTEM DEVIC6 r �, � • ' <br /> SEFiVES: �'�i cc,�'l'"~ .. <br /> CHECK VALV� CHECK VALV�# PR�S. DIF. PRES. D!F <br /> , #� 2 . ACROSS#1 � WH�N RELIEF STRAINER <br /> CHECK OPEN <br /> L�AKED ( ) �EAKED ( ) NONE <br /> EST BEFORE REPAIRS CLOS�D ( ) CLOSED ( ) � .—�S� ^ps� CLND ( ) . <br /> FIIVAL T�ST CLOS�D -'�� CLOSE� "� psi �"-' psi <br /> 17ESCRISE <br /> REPAIR <br /> Certification: � <br /> I hereby cert�fy that the foregoing date to be correct and that the tested device is functioning <br /> within the limits of the standards. <br /> FIRM NAME: EGAN MECHANICAL CONTRACTORS ADDRESS: 7625 BOONE AVE_ NO. <br /> gy.- TESTER'S CERTIFiCATION #��� �� PHONE #: 763-595-4300 <br /> Egaa Compa[e3es, �nc. FAX#k: 763-595-4346 <br /> SIGNA7URE OF C�TIFIED YESTCR <br /> Egan Mechanica! ( Egan-MeKav biectrical � Nietz Electric, Inc. ( Eoan AutomatAon � lnterGad I �g� Servfcc <br /> An A1�irmative ACYron/�qual Qpporr��ain��nap1�>ver <br /> BZ/90 3�Jvc NG'�0� 31t�Q 558Z�9_�9� ?S �0� 800'f8�l8E, <br />