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520 Front Avenue RECF/ � <br /> i) O O LSJ)f' St. Paul, MN 55117 JUNE, Pe <br /> Ph: 651-487-1061 Cir), 2ZD09 <br /> MECHANICAL SERVICE Fax: 651-489-0141 °FOR°,ro <br /> BACKFLOW PREVENTER TEST REPORT <br /> Address City Zip <br /> 071_000 Ox 0-16,1,4-D ie 0 crnv/00 <br /> Owner Contact Name Telephone <br /> AE-r- cOe)ielt <br /> Location Syst m Served <br /> Make Model Serial Si e1/ <br /> LJ kZrS 6cfjM-2 "?Vi- <br /> Install Date Rebuild Due Date <br /> `LOO& 20/ <br /> RP Check Valve#1 Differential Pressure Relief Valve Check Valve#2 <br /> Assembly Leaked Opened at 3'(f, psid Leaked <br /> Closed �,(O Did not open Closed 1,9 <br /> m <br /> a <br /> a. <br /> w <br /> cc <br /> Final Closed (6 • c" Opened at `3: Cr psid Closed 7• 4 <br /> Test reduced pressure <br /> Double Check Valve#1 Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> cc <br /> a <br /> w <br /> cc <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 /> Cl_ <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: 4 570 <br /> Tested by (Print Name) 4.4.-1 A-1(.44- Certification Number 472-4 S ( '"-1--- <br /> White-City Yellow-Customer Pink-Office <br />