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1633 Eustis Street <br /> A\I- ' Q Saint Paul,Minnesota 55108-1288- <br /> (651) <br /> 5108-1288(651)645-0451 'FAX:(651)642-5591 <br /> 7S Years of F�ccellerxe http:Nwww-newrned'•c°n' <br /> 1633 Eustis Street 4T15 X260 <br /> Saint Paul MN 65108-1288 BACKFLOW Eff)NIM T S T' Annual Testing of <br /> (612)645-0451 DATER.PZ Valves <br /> : <br /> Site Name: b to L E S co L Job# lc - <br /> SRe A s- C 7 L 6h go. Tip Dods: s <br /> owner: Phone <br /> O*Tw Ad&e= CiIY: Zp code: <br /> Make and SIM_ SERIAL.#: <br /> Model of. � CV 4 <br /> LOCATION <br /> OF DEVM �1 Al <br /> SERVES WHAT <br /> SYSTEM S®k I J K L E OZ <br /> Check Value#1 Chea Valve#2 Pres.DK Pres.DK Strainer <br /> Across#1 Wben Relief <br /> Check Opens <br /> Test Leaked( Leaked( ) — PSI — PSI <br /> Before Gose Cbse �� cm <br /> Repair <br /> Dew" 7, <br /> ReDair <br /> Fb-ml I.Aaked Leaked PSI PSI None <br /> Test Close O Close O Mod ( ) <br /> Materials <br /> Used <br /> CERTIFICATION: <br /> I hereby certify the foregoing data to be correct and that the tested d@vioe is f rKftfg whin the WAS of the stwidards. <br /> FIRM NAME: NEWN N.55108 <br /> BY: CERTIFICATION#: /�� d/r PHONE: <br /> DATE: REMARKS-.' <br /> - <br /> 13 INSTALL STD REBUILD ORIGINAL INSTALLATION DATE: c� <br /> DATE OF LAST REBUILD: <br /> BFPTR REV. 913199 <br />