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520 Front Avenue <br /> ii) 0 0 LS) 9 St. Paul, MN 55117 <br /> Ph: 651-487-1061 <br /> MECHANICAL SERVICE Fax: 651-489-0141 <br /> BACKFLOW PREVENTER TEST REPORT <br /> Address City Zip <br /> pee) Ott) Cittc-rer-f Ulf 40 Owe Na <br /> Owner Contact Name Telephone <br /> /V161- eAclreIt <br /> Location Sys em Served <br /> L- 59 frT* C-c- opt <br /> Makedel Serial Siz <br /> Atm o� l <br /> 122`3t/fq g'/Z <br /> Install Date Rebuild ue Date <br /> -2_0°? /012 <br /> RP Check Valve#1 Differential Pressure Relief Valve ( Check Valve#2 <br /> Assembly Leaked Opened at '/, Z- psid Leaked <br /> Closed S./ Did not open Closed /, Z <br /> co <br /> cc <br /> a <br /> a <br /> w <br /> cc <br /> '/ <br /> — <br /> Final Closed S,-I Opened at ', Z 4 <br /> psid Closed , - <br /> Test reduce pressure <br /> Double Check Valve#1 Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> cc <br /> a <br /> a <br /> w <br /> cr <br /> Final Closed Opened at <br /> Test <br /> Pressure Check Valve Air Inlet <br /> Vacuum Leaked Did not open <br /> Breaker <br /> Closed Opened at <br /> co <br /> CC <br /> CL <br /> w <br /> o= <br /> Final Closed Opened at <br /> Test <br /> Comments/Notes: <br /> Sign and Dat- tag <br /> i7 <br /> Certified Correct. Signedf/( <br /> Date Tested: - 5 O G <br /> Tested by (Print Name) /4 e Certification Number 02-£(S 1 <br /> White-City Yellow-Customer Pink-Office <br />