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1301 L'Orient St, <br /> DooDy St, Paul, MN 55117 <br /> Ph;651-487-1061 <br /> MECHANICAL SERVICE Fax:851-4890141 <br /> BACKFLOW PREVENTER TEST REPORT <br /> Address City Zip <br /> f 10 c k o cstcCN'-4,,_0 20 6"x UN0 <br /> Owner Contact Name Telephone <br /> MET Co v u C f L <br /> Location System Served <br /> (-- toe) <br /> Make Model Serial Sz��e <br /> LOA Tr, cgot.,tcZ 2_g7q / / y <br /> Ins ll DV R� V gue Date <br /> OU <br /> RP Check Valve#1 Differential Pressure Relief Valve Check Valve#2 <br /> Assembly Leaked Opened at 3,I psid Leaked <br /> Closed g ,fp Did not open Closed w(`/ <br /> cc <br /> o_ <br /> w <br /> cc <br /> Final Closed O -CP Opened at 3 , 1' psid Closed 6, € / <br /> Test reduced pressure <br /> Double Check Valve#1 I Check Valve#2 <br /> Check Leaked Leaked <br /> Valve Closed <br /> Closed <br /> cc <br /> a <br /> a <br /> w <br /> o= <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 /> Tc <br /> a <br /> Lu <br /> cc <br /> Final Closed Opened at <br /> Test <br /> Comments/Notes: <br /> Sign and Date tag <br /> Certified Correct. Signed Date Tested: 4/ /o <br /> Tested by (Print Name) if✓`-4C. Certification Number 6145/ " <br /> White-City Yellow-Customer Pink-Office <br />