HomeMy WebLinkAbout2018-06-11 RPZ Test Report - Swimming Pool BACKFLOW PREVENTOR TOR (R - Z) TEST REPORT
JOB ADDRESS(THE PHYSICAL ADDRESS OF THE RPZ(>): NAME OF BLDG,SUITE NUMBER AND/OR BUSINESS NAME
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OWNER/OCCUPANT OR RESPO SIB PARTY/CONTACT PERSON: CONTACT PHONE:
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TYPE OF WORK:
) „,-W0 INSTALL #7o TEST 0 OVERHAUL/REBUILD 0 REMOVE DATE COMPLETED: b 1)._) „,-
WHEN
HEN WAS THE LAST OVERHAUL/REBUILD DATE: �}
DEVICE LOCATION IN BLDG: mc'
1 7ty n FLOOR#: ROOM#:
SERVES WHAT SYSTEM: n-y ) y,,,q I &?Pal_
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MAKE: 1)40s MODEL#: �//SL. SIZE: ✓/�,, k SERIAL#: j 10 Lp }j
#1 CHECK VALVE RELIEF #2 CHECK VALVE
PSUDIFF PSIIDIFF
TEST BEFORE REPAIRS
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FINAL TEST x ! g°()
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DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER
OF THE DEVICE REMOVED):
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CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that the tested
device is functioning within the limits of the standards. / } I
Name(Print i ? { I- ? Signature: Date:i" el
State of MN Certificate Number: 1D5JPLI(O BF_
COMPANY NAME:3 Ltdi "P,41._, 11019� CO M LS CONTRACTOR LICENSE#: RYi
COMP ANY ADDRESS: 7731 0- "`
COMPANYPHONP#: A .e . '�)
CITY _ JI.- J, STATE: ZIF'' CONTACT PERSONIPHON'E#. iliZe ft,