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� <br /> FROM : � • FAX N0. : Aug. 28 2005 10:21PM P6 <br /> . � .7G25 Boone Avenve Nortti <br /> M Drtwklyn Park,•MN 5542R <br /> � ��11 Se�W Main 763.544.4131 � <br /> � �ax 763.595.4346 <br /> An$gan Compa�ny . www ega�co.c.om <br /> BACKfLOW PREVENTL�R TE'ST R�POR.T <br /> (nstructiorts to Certlfied 7esters: All infOrmaGOn mt�st be T ed or Clearl rinted in blaCk ink � <br /> SITE ADDRESS: p�.�, � � -� <br /> s �rv.� a� z�P: S 39 �r, <br /> 4CCUPANT_ �,�,�-�r o�'� PHONE: T�ST DAT�: �����-» —�- <br /> DEVICE MAKEIMOD�L: � S d n�t I�ZE: a•r r..,. � ... ,. SERIAL NO. .S� <br /> DEVICE E.00ATlON: ,�j o � � . � <br /> SYSTEM DEVICE <br /> SERVES: /�J�Q/�-G. v � <br /> CH�CK VAl.V� CHECK VALVE# � PR.ES.�DIF. PRES. DIF <br /> � #1 2 ACROSS#1 WHEN RELfE� STRAINER <br /> CHECK OPEN <br /> ES7 BEFORE REPqIRS ��KED ( ) LEAKED ( ) �SOps� �� � NON <br /> CLOSED CLOSED�� � C[.ND ( ) <br /> � - <br /> FINAt�TEST CLOSED ( ) CLOSED ( ) �,psi __,nsi ' � <br /> DESCRfBE u� � <br /> REPAIR <br /> Certification: . <br /> I hereby certify that the foregoing date to be correct and that the tested cievice is functioning <br /> within the limits of the siandards. � <br /> FIRM AME: EGAN MECHANICAL CONTRACTORS ADDRESS: 7625 BOONE AVE. NO. � <br /> BY• �'�- TESTER'S CERTIFICATfON #�i�o3�o3'7--'�SMON�#: 763-585-4300 <br /> oF imr�sr�n E�an Companees,Inc. FAX#�: 763-595-4346 <br /> Egan Mechanicai i Egan-McKay�Icctrical � Nietz�lcctric, inc, 1 Egan Aulomation ( InterCl�d � Egan Service <br /> An A�'`nm�r�ive Action/,E'qz�a!U/�portuniry Emp/v�rr <br />