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RFc��V 520 Front Avenue <br /> D 0 0 D)Y' <br /> Rely Fp St. Paul, MN 55117 <br /> no , 1 ?00? Ph: 651-487-1061 <br /> MECHANICAL SERVICE pF oliaFax: 651-489-0141 <br /> BACKFLOW PREVENTER TEST REPORT <br /> Address <br /> 1060 Old p City Zip <br /> C2r{,�„ ct i� �D O LDt v <br /> Owner 0 / Contact Name Telephone <br /> t 1 Cdr pct C <br /> Loc0oSys m Served <br /> LL �"j l C F (A"% <br /> Make Model Serial Size <br /> iwkfI5 909 122`0 4 9 1 �/z <br /> Install ate/ Rebuild Due Date <br /> 5 /$ ©? 'lo I Z <br /> R / Check Valve#1 Differential Pressure Relief Valve Check Valve#2 <br /> Assembly Leaked Opened at psid Leaked <br /> Closed Did not open Closed <br /> cc <br /> w <br /> c <br /> Final Closed ' =Z Opened at 1; 0 psid Closed 2 , <br /> Test reduced pressure <br /> Double Check Valve#1 Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> in <br /> cc <br /> a <br /> a <br /> Lu <br /> m <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 /> cc <br /> a <br /> a <br /> w <br /> cc <br /> Final Closed Opened at <br /> Test <br /> Comments/Notes: <br /> Sign and Date tag <br /> Certified Correct. Signed Date Tested: 5 lig <br /> 0-7 <br /> Tested by (Print Name) ii;b4- JL- ° ' "'11-6 Certification Number 467 -r <br /> White-City Yellow-Customer Pink-Office <br />