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� � <br /> 09/25/2013 01:38 7637672855 DALE BOCAN PAGE 01/01 <br /> � <br /> ���� �t? O � — c� �f' Z <br /> �,�,e;.,��.,��,�......I C7�t rf'S F-��� �Oh D. <br /> BACKFLOW PREV,ENTER TEST REPORT <br /> �nstn.�cGons to Certiflgd Testers: All informaBon mWt beT ed or clear� rinted in black ink <br /> SITE AODRESS: �� <br /> �/ 21P: ,• �f <br /> OCCUPANT; ,:' �� HONE: , <br /> . TEST DAT�. — ,,� -�.� <br /> DEVICE MAKE/MODEL: l�� <br /> �s 9 �' zE: SERIAI.NO. � S <br /> DEVICE LOCATION: /Y <br /> SYSTEM DEVICE / <br /> SERVES� �1�cJ�.,p, . <br /> CHECK VALVE CHECK VAI.,VE# PRES.DIF. PRES.DIF <br /> #1 z ACROSS#1 WHEN RELIEF STRAINER <br /> CHECK OPEN <br /> EST BEFORE REPAIRS ��KED( ) LEAKEO( ) <br /> CI.OSED ( ) CLOSED( ) �..PS� ,_ps� NONE <br /> CLND ) <br /> FINA�TEST C�OSED � LOSE 4�si �•v�- <br /> � �'^ <br /> DESCRIBE . <br /> REPAIR "� <br /> Certification: <br /> I hereby certify that the foregoing date to be correct and that the tested device is functioning <br /> within the Ilmits of the Standards. <br /> FIR ME; AN COMPANY ADDRESS: 7625 BOONE AVE. NO. BROOKLYN PARK M 55428 <br /> S � � TEST�R'S CERTIFICATION# PHONE#: 763-595-4300 <br /> icw�rur�� F CE(�'t�FIED 7E$'fER F�/�#: 763-595-4346 <br /> i <br /> i <br /> � <br />