HomeMy WebLinkAbout2012 - Backflow preventor test report bolder Plumbing & Heating, LLC.
7760 County Road #26 Maple Plain, MN 55359
Phone: 763-479-1942 Email: robdolder@aol.com
BACKFLOW PREVENTOR (RPZ) TEST REPORT
JOB ADDRESS: 39 A) /%J W,°,,-e , v
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OWNER/OCCUPANT/CONTACT PERSON;//lel L t.C. / e.e / CONTACT PHONE:
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DEVICE LOCATION: 5)40,01` `,yiyy7 FLOOR#: /j-- ROOM#: —
SERVES WHAT SYSTEM: geG , ,// d� / ! f� 5
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MAKE: P 1� MODEL#: 97 R /7 SIZE: , SERIAL#: oh'?
INSTALL D�A(TT/E(((,,, JJJ ,
((((MMONNTH/DAY/YEAR): OVERHAUL DATE/ (MONTH/DAY/YEAR): TEST DATE(MMONTH/DAY/YEAR):
(DO NOT PUT A FUTURE DATE IN THIS BOX)
/2- )/0 //- l- ;?D /Z
#1 CHECK VALVE RELIEF #2 CHECK VALVE
PSI/DIFF PSI/DIFF
TEST BEFORE REPAIRS
FINAL TEST 96 2„ 5 1
DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER
OF THE DEVICE REMOVED):
TEST DONE BY(PL E PRI T FIRST 8 LAST N E):
CERTIFICATION NUMBER:
STATE OF MINNESOTA
BACiFLOW RPZ TESTER UNLIMITED esr9
License# 061486-BFB~
Expiration Cate
Original Issued Date 04/16/1998
ROBERT W DOLDER
404 GREEN AVENUE SOUTHEAST
WATERTOWN, MN 55388
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Dolder Plumbing & Heating, LLC.
"- , 7760 County Road #26 Maple Plain, MN 55359
Phone: 763-479-1942 Email: robdolder@aol.com
BACKFLOW PREVENTOR (RPZ) TEST REPORT
JOB ADDRESS: 3 / r/4 w.,,,'v,e 00 r
OWNER/OCCUPANT/CONTACT PERSON: %c �� %re.-
0—
DEVICE
CONTACT PHONE:
LOCATION: -l� ./�/i/eY ,/ 31 re55 _7 FLOOR#: /
/� ROOM#:
SERVES WHAT SYSTEM: /`� {/ Le �
MAKE: &.i, / MODEL#: z ' SIZE: /7 SERIAL#: )7,2 el/5K 5
INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MOW-II/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR):
(DO NOT PUT A FUTURE DATE IN THIS BOX)
a- 20/0 //-i-2c2
#1 CHECK VALVE. RELIEF #2 CHECK VALVE
PSI/DIFF PSI/DIFF
TEST BEFORE REPAIRS
FINAL TEST 7 6 /,„ 70
DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER
OF THE DEVICE REMOVED):
TEST DONE BY(PL S PRINT FI- NAME):
ir,
CERTIFICATION NUMBER:
STATE QF MINNESOTA
BACXFLOW RPZ TESTER UNLIMITED t'itfiyrq
License# 061486-BF ,
Expiration nate !
Original Issued Date 04/16/1998 4,� y
ROi3ERT W DOLDER
404 GREEN AVENUE SOUTHEAST
WATERTOWN, MN 55388
bolder Plumbing & Heating, LLC.
7760 County Road #26 Maple Plain, MN 55359
Phone: 763-479-1942 Email: robdolder@aol.com
BACKFLOW PREVENTOR (RPZ) TEST REPORT
JOB ADDRESS: 3`/d f, J/l A) pnv-e
OWNER/OCCUPANT/CONTACT PERSON: , LA / e 777: CONTACT PHONE:
P'
DEVICE LOCATION: iv,Coz.e.( IJi FLOOR#: . �� ROOM#:
SERVES WHAT SYSTEM: a//` C�� GL��
I.�/ /�C�? mac) f --CC����111 �>` Q.�5
MAKE: &h ,,, fizz MODEL#: /y (� g SIZE: SERIAL#: /l v33
INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH,/�'DAY/YEAR): TEST DATE(MONTH/DAY/YEAR):
(DO NOT PUT A FUTURE DATE IN THIS BOX)
/Z_'-/v //-/- Zoiz_
#1 CHECK VALVE RELIEF #2 CHECK VALVE
PSI/DIFF PSI/DIFF
TEST BEFORE REPAIRS
FINAL TEST •
cv
DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER
OF THE DEVICE REMOVED):
r '
TEST DONE BY(PL PRINT AME):
j. , CERTIFICATION NUMBER:
STATE OF MINNESOTA
BACXFLOW kPZ TESTER UNLIMITED °F xesT9
License# 061486-BF "`"
Expiration Datebirct
Original Issued Date 04/16/1998 �y�
ROBERT W DOLDER
404 GREEN AVENUE SOUTHEAST
WATERTOWN, MN 55388