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520 Front Avenue <br /> ii) it <br /> O LS)1/' <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 /> /000 Ot/) ClotsTRt.. 13,44/ 21) Crn.v,,Jct <br /> Owner <br /> me-i CovPc/L Contact Name Telephone <br /> Location Syslprn Served <br /> L—5e7 f 7e-7 ,Lc- <br /> M�R TSde� Serial Size <br /> G IZZ75(/ 9 / 17z <br /> Install Date Rebuild.,D�eDate <br /> 7 20 G <br /> RP Check Valve#1 Differential Pressure Relief Valve Check Valve#2 <br /> Assembly Leaked Opened at 3 •' psid Leaked <br /> Closed 1 (o Did not open Closed (--/ <br /> co <br /> cc <br /> a <br /> w <br /> tr <br /> Final Closed 1, ,i, Opened at 3. psid Closed II, <br /> Test reduced pressure <br /> Double Check Valve#1 Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> 0D <br /> cr <br /> w <br /> 2 <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 /> riw <br /> w <br /> I <br /> Final Closed_ Opened at <br /> Test <br /> Comments/Notes: C LLQ l" � CAL E Fncr //��r;^ /2 LL(C-P- <br /> Sign and Date tag <br /> Certified Correct. Signed Date Tested: 4' / /42 <br /> Tested by (Print Name) / -/YL / 1 $ ( Certification Number az-467"r <br /> White-City Yellow-Customer Pink-Office <br />