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At <br /> 1633 Eustis Street <br /> St.Paul, MN 55108-1219 <br /> Cm*arde%.Im (651)645-0451 FAX:(651)642-5591 <br /> 7S Years of Excelk Ke httpJ/www newmedi.com <br /> 1633 Ets6s Street 47152260 <br /> NmvMb& <br /> Saktt Patd MN 55108-1288 BACKFLOW PREVENTER TEST REPORT Annual Tesft of <br /> (651)646"1 DATE: R.P.Z Valves <br /> Site Name: D .bb 8 <br /> Sloe Address: ©Ab (kwdg R-44 nap-= zo code: . ' <br /> oee <br /> comm Phoma#. <br /> owner: <br /> Monet. <br /> Owner Address: <br /> Mace and SIZE: SERIAL.M <br /> Model O' — /" <br /> Device: <br /> LOCATION #Zq3-621 <br /> OF DEVICE: <br /> SERVES WHAT / <br /> SYSTEM: O � ,; U;w ` 1 R <br /> Chea Nal"81 V"82 D1L Pres.Df. sber <br /> Across#1 When Relief <br /> Check Opens <br /> .T (Leaked( ) Leaked( ) _ PSI _ PSI None( ) <br /> Descxbe <br /> Repair <br /> �� � Cind <br /> dr ( ) <br /> Repair <br /> Fktal Leaked( ) Leaked( ) _ PSI _ PSI NorteTest CIM Ckm CInd <br /> ( ) <br /> Materials <br /> Wed <br /> CERTIFICATION: <br /> I hereby certify the bregoi g data W be corned and that the Wsled device Is AmdbnbV wM*t the Ids of the sW dards. <br /> FIRM NAME: / b1p9mCO.M. ADDRESS- 1633 EUSTIS STREETT STT.PALL MN.55108 <br /> BY: G CERTIFICATION : '/ PHONE: <br /> DATE: S. <br /> O INSTALL "ST O REBUILD ORIGINAL INSTALLATION DATE: <br /> DATE OF LAST REBUILD: <br /> BFPTR REV. 1118102 <br />