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Dolder Plumbing & Heating, LLC. <br /> 7760 County Road #26 Maple Plain, MN 55359 <br /> ---A61.61----'1. <br /> Phone: 763-479-1942 Email: robdolder@aol.com <br /> BACKFLOW PREVENTOR (RPZ) TEST REPORT <br /> JOB ADDRESS: ?�/] /� j/0 ,W/tA-e 4,10.1 dv ,j , i 5-51 <br /> OWNER/OCCUPANT/CONTACT PERSON Ld /� (e-----"/ /' J) CONTACT PHONE: <br /> DEVICE LOCATION: 5/7,7r/n///� ,,,,,cc..",- /^ .----1 FLOOR#: / ROOM#: <br /> SERVES WHAT SYSTEM: ,,// / 1k <br /> A/Oh O/`i fes' Biu , <br /> MAKE: mitt- MODEL#: 9 57 E /2 SIZE: g SERIAL#: p3 40/iy, <br /> INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): <br /> (DO NOT PUT A FUTURE DATE IN THIS BOX) <br /> /2-2q-2c /) <br /> #1 CHECK VALVE RELIEF #2 CHECK VALVE <br /> PSI/DIFF PSI/DIFF <br /> TEST BEFORE REPAIRS <br /> FINAL TEST <br /> 94., 2, <br /> $ , 5 <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(PLEASEPRINT FIRST LAST NAME): <br /> e4 PL%/1 <br /> P� CERTIFICATION NUMBER: <br /> STATE OF MINNESOTA <br /> BACXFLOW kPZ TESTER UNLIMITED ;4es�q <br /> License# 061486-BF ` ` •0 <br /> Expiration Date , J <br /> Original Issued Date 04/16/1998 <br /> ti '..,,,401, <br /> ,401, <br /> ROBERT W DOLDER <br /> 404 GREEN AVENUE SOUTHEAST <br /> WATERTOWN, MN 55388 <br />