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bolder Plumbing & Heating, LLC. <br /> 7760 County Road #26 Maple Plain, MN 55359 <br /> Phone: 763-479-1942 Email: robdolder@aol.com <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: 39 A) /%J W,°,,-e , v <br /> pox <br /> OWNER/OCCUPANT/CONTACT PERSON;//lel L t.C. / e.e / CONTACT PHONE: <br /> `,.¢ o." jV <br /> DEVICE LOCATION: 5)40,01` `,yiyy7 FLOOR#: /j-- ROOM#: — <br /> SERVES WHAT SYSTEM: geG , ,// d� / ! f� 5 <br /> r "e"--N <br /> / J! <br /> MAKE: P 1� MODEL#: 97 R /7 SIZE: , SERIAL#: oh'? <br /> INSTALL D�A(TT/E(((,,, JJJ , <br /> ((((MMONNTH/DAY/YEAR): OVERHAUL DATE/ (MONTH/DAY/YEAR): TEST DATE(MMONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> /2- )/0 //- l- ;?D /Z <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST 96 2„ 5 1 <br /> DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER <br /> OF THE DEVICE REMOVED): <br /> TEST DONE BY(PL E PRI T FIRST 8 LAST N E): <br /> CERTIFICATION NUMBER: <br /> STATE OF MINNESOTA <br /> BACiFLOW RPZ TESTER UNLIMITED esr9 <br /> License# 061486-BFB~ <br /> Expiration Cate <br /> Original Issued Date 04/16/1998 <br /> ROBERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />