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.ASSOCIATED <br />i <br />1257 Marschall Road, P.O. Box 237 <br />Shakopee, MN 55379 <br />Phone: (952) 445-5100 <br />Fax: (952) 445-5119 <br />E-Mail: criechers@associatedmechanical.com <br />REGULATED <br />BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT <br />COMPLETE JOB ADDRESS (INCLUDE <br />? R <br />Apt/Unit it) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER <br />, Gv T <br />G1 <br />L o <br />APPLICANT COMPANY NAME <br />Associated Mechanical <br />CONTRACTOR LICENSE # CONTACT NAME AND PHONE NUMBER <br />Contractors <br />L098 22749 Charlie Riechers 952-445-5100 <br />ADDRESS <br />PO Box 237 <br />CITY STATE LP EMAIL <br />Shakopee MN 55379 criechers associatedmechanical.com <br />TESTER NAME <br />Dave Muellerleile <br />TESTER CERTIFICATION # PHONE <br />754900 - 43711 952-445-5100 <br />TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # <br />TEST EQUIPMENT SERIAL# <br />TESTING EQUIPMENT CALIBRATION DATE <br />Midwest <br />845-5 <br />05210140 <br />Mo. 4 yr 24 <br />TYPE OF WORK AND FEE INFORMATION (check one) <br />_Install _Relocate <br />Remove Replace and SN# of Replaced Device <br />Rebuild _✓ Test <br />Describe parts and repairs when neeoe�• <br />of information Provided by me to bz ect and th e t device Is fu ctionfng in compU <br />l }ureby cerify the foreg r�B /// <br />C:E.RTIflUI�� ��� TESTERS SIGNATURE <br />C>�e �apter 4714. ILGC ._--BEST DATE• �3 Lcf <br />State of <br />