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Ask Allik Alk <br /> ,toNslewmech <br /> r1% <br /> COMPANIES, INC <br /> 1633 Eustis Street 4715.2260 <br /> Saint Paul MN 55108-1219 BACKFLOW PREVENTER TEST REPORT Annual Testing of <br /> (651)645-0451 f R.P.Z.Valves <br /> DATE: faK <br /> Site Name: )kwo /" yCAM Job# <br /> Site Address: 2z� City: O)eo 4/0 <br /> Zip code: <br /> Contact: 19C Phone#: �P_ WP <br /> Owner. Phone#: <br /> Owner Address: City: Zip code: <br /> Make and SIZE: SERIAL#: <br /> Model ,, >,q �s �e) ? <br /> Device:: W <br /> LOCATION _ <br /> OF DEVICE: P <br /> SERVES WHAT <br /> SYSTEM: <br /> Check Valve#1 Check Valve#2 Pres.Dif. Pres.Dif. Strainer <br /> Across#1 When Relief <br /> Check Opens <br /> Test Leaked( ) Leaked( — PSI _ PSI None( ) <br /> Before Close Close (v� Clnd ( ) <br /> Repair e <br /> Describe <br /> Repair <br /> Final Leaked( Leaked( _ PSI _ PSI None ( ) <br /> Test Close ( ) Close ( ) Clnd ( ) <br /> Materials <br /> Used <br /> CERTIFICATION: <br /> I hereby certify the foregoing data to be correct and that the tested device is functioning within the limits of the standards. <br /> FIRM NAME:: NEWMECH CO. INC. ADDRESS: 1633 EUSTIS STREET ST.PAUL MN.55108 <br /> BY: (� 1 CERTIFICATION#:®� ��`�PHONE: 651-645-0451 <br /> DATE: 2-- RE MARKS: <br /> 0 INSTALL 9?TEST 0 REBUILD ORIGINAL INSTALLATION DATE: <br /> DATE OF LAST REBUILD: (� <br /> BFPTR REV. 1/7/04 <br />