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Me& 1633 Eustis Street . . <br /> St.Paul, MN 55108-1219 <br /> Companies,,.lm (651)645-0451 FAX:(651)642-5591 <br /> 75 Years of Exteller" httpJ/wwwjmvnnech.com <br /> 1633 Eusft Shed 47152260 . <br /> Saint Paul MN 55108-9288 BACKFLOW PREVENTER TEST REPORT Annual of <br /> a fib%v <br /> (651)645.0451 ( / -3 R P.Z.y l <br /> DATE: Ir)OS I`C) <br /> Site Name: 6)qjo l) Job# SS <br /> sire Address: 6 � �, L `' © code: 5 s, <br /> cor> — Phone#: <br /> o- 9-- <br /> ow w. Phona#: <br /> owner Address: W. zip code: <br /> Make and SIZE: SERIAL#: <br /> Modelf r <br /> Device: <br /> LOCATION <br /> OF DEVICE: <br /> SERVES WHAT <br /> SYSTEM: <br /> Chec'kVaIve#1 Check awe#2 PreL DIE Pres.DIE stub r <br /> Across#1 When Relief <br /> Check Opens <br /> Ted Leaked LeakedBefore (Nose. (Q/� Close ( PSI Clnd ( ) <br /> Repair 3e <br /> Descrbe <br /> Final Leaked( ) Leaked( _ PSI _ PSI Nom ( ) <br /> Test Close ( ) Cl.se ( ) Clnd ( } <br /> Materials <br /> Used <br /> CERTIFICATION: <br /> I hereby cm*ft 9 data to be c"reot and that the tested device is firn ft ft v+ fire 1&rrits of the standards. <br /> FIRM NE,,.W^^N m CO.qr . ADDRESS: 1633 EIMIS STREET ST PAIR MN.55108 <br /> BY: <br /> DATE• t�7j REAAARICS• <br /> El INSTALLLEST 13 REBUILD ORIGINAL INSTALLATION DATE: <br /> DATE OF LAST REBUILD: <br /> -BFPTR REV. 1/18{02 <br />