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o _ R <br /> Vc <br /> OMP y V B�� G <br /> 1633 Eustis Street 47152260 <br /> Saint Paul MN 55108-1219 BACKFLOW PREVENTER TEST REPORT Annual Testing of <br /> (651)645-0451 / R.PZ Valves <br /> DATE: �P�'�'�U <br /> Site Name: rone SGKQQL Job# c3 �I ;Wco <br /> Site Address: 0.Q Q Q L t9 C Jj1,a.G �Jc� 111 ' l"�i� ZIP cwe- <br /> .Contact Q K vt Q 5 cr"n p Phone#: <br /> owner: Phone M <br /> Owner Address: Cityy. ZO code: <br /> Make and <br /> Model Of we.,-.-f-r5Devlm <br /> 0 r SIDE: S <br /> Lf rWHON <br /> OF DEVICE: go,-wPP <br /> SERVES WHAT <br /> SYSTEM: U`W,( W? v,%vTaf <br /> Check Valle#1 Check valve#2 Pres.Mr. Pres.Dil SlnM <br /> Across#1 When Relief <br /> Check Opens <br /> Test Leaked( Leaked( _ PSI _ PSI None( ) <br /> Betore Close ( ) Close ( ) Cind ( ) <br /> RepaIr <br /> Res«MeOU.,Lp <br /> Final Leaked( ) Leaked( ) _ PSI _ PSI Nate 1.4 <br /> Tek . Close Close � J cind ( ) <br /> Materials <br /> tiled - <br /> CERTIFCAMM: <br /> I hereby certify fto forWft data to be coned and that ft tested device Is Uwft g within ft W&of the slandards. <br /> FIRM NAME: NEWyMQECH CO.INC. ADDRESS: 1633 EUSTIS STREET ST.PAUL MN.55108 <br /> BY: r�� 6�'�UE�l CERTIFICATION#: �'��� PHON€: 651-64y-0451 <br /> DATE; o�-Qj—Q REMARKS• <br /> O INSTALL A-TEST BUILIJ ORIGINAL INSTALLATION DATE 2O00 <br /> DATE OF LAST REBUILD: <br /> BFPTR REV. 117/04 <br />