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•�``�r E an M�chanical Contractors Inc. � <br /> � � � <br /> � 13uilding Iiitegr.ited Solutions'� <br /> BACKFLOW PREVENTER TEST REPORT <br /> Instructions to Certified Testers: All information must be typed or clearly printed in black ink. <br /> SITE ADDRESS: � �O ZIP: <br /> � �o�f s�� �.� <br /> OCCUPANT: PHONE: TEST DATE: <br /> IY�,'r�n.�-�,�. �' -�,- .� --�� � o--�v --�v <br /> DEVICE MAKE AND MODEL: SIZE: �� SERIAL NO. <br /> �-s �� --� � ��s y�.�' <br /> DEVICE LOCATION: /� 1 ,�. <br /> �o � 1�� � T;'/',e /"�'��f,�� -� (',�.�.� <br /> DEVICE SERVES WHAT SYSTEM: �-–� jQ 1__�, � � � ��� <br /> /`�/',2 /'o /zf'' u O✓l � � �✓ <br /> r <br /> CHECK VALVE # PRES. DIF. PRES. DIF WHEN <br /> CHECK VALVE #1 2 ACROSS #1 RELIEF OPEN STRAINER <br /> CHECK <br /> TEST BEFORE LEAKED ( ) LEAKED ( ) NONE {�- <br /> REPAIRS CLOSED ,� CLOSED (�^ —Psi —PS� CLND ( ) <br /> / � <br /> FINAL TEST CLOSED ( ) CLOSED ( ) _psi _psi <br /> DESCRIBE <br /> REPAIR <br /> f� �.�/ 6 <br /> CERTIFICATION: <br /> I hereby certify that the foregoing date to be correct and that the tested device is functioning <br /> within the limits of the standards. <br /> FIRM NAME: EGAN MECHANICAL CONTRACTORS ADDRESS: 7100 MEDICINE LAKE ROAD <br /> �l�/�F' ��C��1 TESTER'S CERTIFICATION #�0-�3�v3`7�PHONE #: 763-595-4300 <br /> SIGNATURE OF CERTIFIED TESTER FAX #: 763-595-4346 <br />