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520 Front Avenue <br /> Li) O OjJ)f' <br /> 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 /> /0 0' OLD C/1y57-A- r��4if KO a - <br /> la, <br /> _ <br /> Owner Contact Name Telephone <br /> /tier C00,0 C f C <br /> Location System Served <br /> L P0TAixe cd rn <br /> Make Model Serial Size. <br /> Gcl,47Ttj Jeq 12Z 95<<I/ /"2_ <br /> Install D to Rebuild Due Date <br /> �f,f/ r7 20/Z <br /> RP Check Valve#1 Differential Pressure Relief Valve Check Valve#2 <br /> Assembly Leaked Opened at psid Leaked <br /> Closed Did not open Closed <br /> - -- <br /> w <br /> // <br /> Final Closed cP r ( Opened at ; 0 psid Closed <br /> Test reduced pressure <br /> Double Check Valve#1 Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> cccc <br /> w <br /> w <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 /> w <br /> cc <br /> Final Closed Opened at <br /> Test <br /> Comments/Notes: <br /> Sign and Date tag <br /> /7 <br /> Certified Correct. Signed Date Tested: 'S1)9/0 <br /> Tested by (Print Name) 1:2A.3L Al4ite _ Certification Number 02'W-1-- <br /> White-City <br /> 2`W–TWhite-City Yellow-Customer Pink-Office <br />