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C.:k <br /> FCFiv <br /> eb <br /> * REDUCED PRES UR BACKFLOW PREVENTER TEST REPORT d <br /> ESTABLE DOUBLE CHECKS 0/i � <br /> czritikm <br /> If <br /> Service Name: ` - € l Contact Person/Tele: 1 ?.s S J-__1222_ -/ <br /> Address: /UQQ) v/I CSS 4,111,7((City: (9 c dState: /Clii)M Zip: <br /> Device Location: Z-, Serve what system: <br /> Account No: Serial Number: / r A / L//I <br /> Type: Make: Model: 9f 1j C.i 1 Size: / 1.2- <br /> Rebuild <br /> 2Rebuild Due Date: 2' 0 /•°1— Test Due Date: <br /> Annual Check Valve#1 Check Valve#2 cc// Differential Pre ure Relief Valve <br /> Report Pressure 7- .2. Pressure T• Opened at j psid reduced pressure. <br /> Did not open <br /> Cleaned Cleaned Cleaned <br /> Replaced Replaced Replaced <br /> R Disc Disc Disc <br /> E Spring Spring Spring <br /> P Guide Guide Guide <br /> A Pin Retainer Pin Retainer Diaphragm, Large <br /> I Hinge Pin Hinge Pin Lower <br /> R Seat Seat Upper <br /> S Diaphragm Diaphragm Diaphragm, Small <br /> Other, describe Other, describe Lower <br /> Upper <br /> Spacer, Lower <br /> Other, describe <br /> f ,' ] Sign and date Tag <br /> The above is certified correct. Signed <br /> y......./< ,� k-__ - DateTested: 5--- 3- // <br /> Tested by (Print Name) t � 1 , `(�aCertification Number a✓t2C1 T1sic <br /> Company Name: G\C ( kLt II Q.i/t,. '10,„�- License Number 0 606 ! LIPel/ <br /> Company Telephone Number 3\ Q-. 01 a-T <br /> All sections of this report must be completed. <br /> Return to: Saint Paul R- ; nal Water Services • <br /> ATTN: Lynda -re '•do- Production ',AL <br /> 1900 Rice <br /> Saint Pau , MN 55113 <br /> Return with fee: Payable to the Board of Water Commissioners <br />