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Amk AWL Ask xiewmech <br /> COMRN ES, we <br /> 1633 Eustis Street 4715.2260 <br /> Saint Paul MN 55108-1219 BACKFLOW PREVENTER TEST REPORT Annual Testing of <br /> (651)645-0451 DATE: x e; /�f� R.P.Z.Valves <br /> '� -� <br /> Site Name: �® o `�� C C Job# 6�141-1 <br /> Site Address C �� �' L City: Zip code: <br /> Contact: / Phone#: _ <br /> Owner C. Phone M <br /> Owner Address: City: Zip code: <br /> Make and SIZE: SERIAL#: <br /> MedalA A � <br /> Device:: Cid <br /> LOCATION <br /> OF DEVICE: <br /> SERVES WHAT <br /> SYSTEM: 0 r, <br /> Check Valve#1 Check Valve#2 res.Dif. Pres.Dif. Strainer <br /> Across#1 When Relief <br /> Check Opens <br /> Test Leaked( Leaked( _ PSI _ PSI None( ) <br /> Before Close �'� Close ( -6 <br /> Clnd ( ) <br /> Repair ` <br /> Describe <br /> Repair <br /> Final Leaked( Leaked( — PSI _ PSI None ( ) <br /> Test Close O Close O 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: CERTIFICATION#: 0/0Zr PHONE: 651-645-0451 <br /> DATE: RE MARKS: <br /> ❑ INSTALL ®-TEST ❑ REBUILD ORIGINAL INSTALLATION DATE: <br /> DATE OF LAST REBUILD: <br /> BFPTR REV. 1M04 <br />