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HomeMy WebLinkAbout2019-07-02 Backflow Preventor (RPZ) Test Reports fril_l_ 001c/' BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS(THE PHYSICAL ADDRESS OF THE RPZ(s): NAME OF BLDG,SUIE NUMBER AND/OR BUSINESS NAME (a 13 sr, oiX 4 Ln). ui\A � �TDE -. . OWNER/OCCUPANT OR RESPONSIBLE PART(/CONTACT PERSON: CONTACT PHONE: CES V1rW ite lY9 I' C_Pelc;15a-40W-9'45Y TYPE OF WORK: 0 INSTALL 0 TEST 0OVERHAUL/REBUILD © REMOVE DATE COMPLETED: 7 -) R WHEN WAS THE LAST OVERHAUUREBUILD DATE: J DEVICE LOCATION IN BLDG: 5 crPng _cr S1 .._ FLOOR#: ROOM#: SERVES WHAT SYSTEM: IY407) MAKE: i ((x' 346. MAKE: ei CJs" SIZE: I/' W SERIAL#: f / #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF i PSI/DIFF TEST BEFORE REPAIRS �' 7 1^ K 1, -o� FINAL TEST DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE R : i j 4/3,z_ tro ia 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 standa ds. Name (PrintO6D P) )OL Signature: Date:—7- z---9 State of MN Certificate Number:OLL 5J 1p"1(O BF �/�j y COry}�n/� 1 COMPANY NAME: Y L- �/`�f Jv(0 ` MPLS CONTRACTOR LICENSE- #: COZO "t COMP ANY ADDRESS: ---2-73) .4 5 COMPANY PHONE#: L�la`gPr1 l CITY: 10-W i!—=LT) STATE:VV ZIP 54c75 CONTACT PERSON/PHONE#: A) lJ II i 1 I -1111_1,31 017 BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS(THE PHYSICAL ADDRESS OF THE RPZ(s : NAME OF BLDG,SUITE NUMBER AND/OR BUSINESS NAME (Pa 1:3 r C)1 ©)X L , , lOYfsiD-F- - OWNER/OCCUPANMxr R RESPONSIBLE PARTY/CONTACT PERSON: CONTACT PHONE: PE- - 0161)\) 95 -to •l'5•3"a TYPE OF WORK: 0 INSTALL (.T TEST 0 OVERHAUL/REBUILD © REMOVE DATE COMPLETED: 7 - . .J WHEN WAS THE LAST OVERHAUL/REBUILD DATE: I DEVICE LOCATION IN BLDG1n� Qf)/ FLOOR#: ROOM#: I SERVES WHAT SYSTEM: 1 j+, i �illy L MAKE: al*A.IS MODEL#: �1 vl SIZE: ;I SERIAL#: 90 9 5 7 {!LL ) (� #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF PSI/DIFF t I TEST BEFORE REPAIRS FINAL TEST 2-, CpV1 5'. Oke f ., Li - DESCRIBE REPAIR IF ANY(IF THIS ISA NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): Cter *:AZ 1 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.�� Name (PrintJ1+ D fl5� O1:- Signature: `/tel Date: l• �? State of MN Certificate Number:01651P1"1'6 -8' 1 COMPANY NAME:-NAY LA-) .-PLIVa'W9 CO MPLS CONTRACTOR LI �' Y) CENSE#: O2 ? • COMP ANY ADDRESS: 7-7,3) .-riR S _ COMPANY PHONE#: 1,42-Vi:75-3) CITY: '1C)I)LD STATE:YF J\} 2IP�-. J CONTACT PERSONIPHOME#: 1A) 1 fn 9 BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS(THE PHYSICAL ADDRESS OF THE RPZ(s): NAME OF BLDG,SUITE NUMBER AND/OR BUSINESS NAME tea3 '3r Clp -MI_ tJ l ti-J__. OWNER/OCCUPANT OR ESPO SI LE PARTY/CONTACT PER CONTACT 0 '� � C 7 d' ICY S -, TYPE OF WORK: 0 INSTALL p TEST 0 OVERHAUL/REBUILD 0 REMOVE DATE COMPLETED: --.7„� �i� WHEN WAS THE LAST OVERHAUUREBUILD DATE: ` I/ AQ DEVICE LOCATION IN BLDG: -�+ ar�G FLOOR#: ROOM#: SERVES WHAT SYSTEM: �r�/'` -�T 4 n/242MAKE: 144 ( /R� MODEL#: /" 4 SIZE: • /r SERIAL#: 43977,...:7 #1 CHECK VALVE RELIEF #2 C CK V LVE PSIIDIFF PSI/DIFF TEST BEFORE REPAIRS I n FINAL TEST J 3 v DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): --r-Er- tK V i 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 �/tastandards. !� �7 2 Name(Print)HD i5E�0>_-i Signature: Date: - (5 State of MN Certificate Number:01051P"I O BF COMPANY NAME:-5I-0 Lt i Yibf i1 Co MPLS CONTRACTOR LICENSE#: 0/3309 COMPANY ADDRESS: .7 73) 9-6- 5 COMPANY PHONE#: l,i 9:151 3) CITY: . I�Ii 1 L-� STATE:VI J ZIP CONTACT PERSON/PHON'E#: yk) I