HomeMy WebLinkAbout2017-06-16 Backflow Preventor (RPZ) Test Reports -X. P.O. Box 240
885 Katydid Lane
Hanover,MN 55341
\OSS UTILITY&PLUMBING
763-497-4577
.
763-497.-3994 Fax
BACKFLOW PREVENTOR (RPZ) TEST REPORT
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JOB ADDRESS: -be fit4 i IT, li. ,., . 1,
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OWNERJOCCUPANTICONTACT PERSON: CONTACT PHONE:
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I DEVICE LOCATION: r,hel,u-t,F( riff.c:),/.1 ce: r 3 (ei t--\,(,) FLOOR#: ROOM#: -1
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I MAKE: 1 ,I L __ MODEL#: 3-25->c e_. IstzE: 1,,',7' // SERIAL#:
INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH/DAY/YEAR): i TEST DATE(MONTH/DAY/YEAR):
(DO NOT PUT A FUTURE DATE IN THIS BOX) I
I ,L7 )1/2-7- t/?°/-7
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#1 CHECK VALVE RELIEF #2 CHECK VALVE I
PSI/DIFF PSI1DIFF
TEST BEFORE REPAIRS
IFINAL TEST ( 's t ( 3, c',
DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER 1
OF THE DEVICE REMOVED):
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TEST DONE BY(PLEASE PRINT FIRST&LAST NAME):
/ ( CERTIFICATION NUMBER;Ro
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COMPANY NAME: VO C)S tn
A... ' .1 4 P(,“1/141,)i i,,,--' ,c-i
, t CONTRACTOR LICENSE#: PC-Ck-C2)G(40
COMPANY ADDRESS: 1 COMPANY PHONE#:
1 CITY: STATE: ZIP: CONTACT PERSON/PHONE#:
P.O. Box 240
885 Katydid Lane
Hanover,MN 55341
VOSS UTILITY&PLUMBING
763-497-457'
763-497-3994 F.1.
BACKFLOW PREVENTOR (RPZ) TEST REPORT
JOB ADDRESS: D
(\,'h'' /1'; 45_ cc osi?
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OWNER/OCCUPANT/CONTACT PERSON: CONTACT PHONE:
DEVICE LOCATION: tiy\cit r scr— FLOOR#: ROOM#:
SERVES WHAT SYSTEM:
MAKE MODEL I 1 1 " SERIAL IP
MODEL#: 1/7 if SIZE: rz
7,4--
INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONTH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR):
(DO NOT PUT A FUTURE DATE IN THIS BOX)
/-*
117Z072
#1 CHECK VALVE RELIEF #2 CHECK VALVE
PSI/DIFF PSI/DIFF
TEST BEFORE REPAIRS
FINAL TEST
DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER
OF THC DEVICE REMOVED):
1 11'4 CA\
TEST DONE BY(PLEASE PRINT FIRST&LAST NAME):
ff CERTIFICATION NUMpER:
COMPANY NAME: VOC>c Lth P tAA.,v-yik7 t>ici CONTRACTOR LICENSE#: rdekt-036(.01
COMPANY ADDRESS: COMPANY PHONE#:
1 CITY: STATE: ZIP: CONTACT PERSON/PHONE#: