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OO ■PAI YES!NG <br /> 1633 Eustis Street 4715.2260 <br /> Saint Paul MN 55108-1219 BACKFLOW PREVENTER TEST REPORT Annual Testing of <br /> (651)645-0451 DATE: Z _ Q 5 R.PZ Valves <br /> Site Name: rV1 QJ6D®�.e �J C nT 01 Job# <br /> Site Address: ®Q ftp '�p crw= QY Q ® Zip code: <br /> contak� V obt Phone M. <br /> Owrher: Phone#: <br /> Owner Address: City: Zip code: <br /> Make and SIZE: SERIAL#: <br /> Model of 1,✓&,tT 5 <br /> of Dom: D,'Jef-- <br /> SERVES WHAT (� <br /> SYSTEM. <br /> Check Valve#1 Check Valve#2 Pres.Dif. Pres.m. Strah>er <br /> Across#1 When Relief <br /> Check Opens <br /> Test Leaked <br /> Leaked O _ PSI PSI Non� ( ) <br /> Betore Close () Close ( ) — <br /> Repair <br /> Describe <br /> Rep—airPSI PSI �� <br /> Fitted Leaked( Leaked( — — <br /> Test . Close - 9q close'� <br /> Materials -2. 3-Lf <br /> Used <br /> CERTIFICATION: <br /> I hereby certify the foregoing data to be torted and that the tested device is fia> mft within the limits of the standards. <br /> FIRM NAME: NEWMECH CO.INC. ADDRESS: 1633 EUSTIS STREET ST.PAUL MN.55108 <br /> BY.. �'9ll�e -�Ie CERTIFICATION#: � PHON€: 651-645.0451 <br /> DATE. r Q V REMARKS: <br /> ❑ INSTALL 1&ZEST BUILL3 ORIGINAL INSTALLATION DATE: ®® <br /> DATE OF LAST REBUILD: <br /> BFPTR REV. UT/04 <br />