HomeMy WebLinkAbout2020-05-18 PVB Test Report - Irrigation SystemJOB INFORMATION
COMPLETE PROPERTY ADDRESS
WHERE DEVICE IS LOCATED:
OWNER/CONTACT
NAME:
DEVICE INFORMATION
WHERE ON THE PROPERTY
15 THE DEVICE LOCATED:
WHATSYSTEM DOES THIS C
LOCK BOX COMBINATION
Plumbing Heating & Air Conditioning, Inc.
15535 Medina Rd, Plymouth, MN 55447
Phone: (763) 473-2267 Fax: (763)473-8565
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OWNER�CONI�C
PHONE:
ALL, irrigation systerns Inusi: be Cesieci yearly, Ste" Ng ONLY
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PERMIT # iNEW IIVSfnj t 5/RFBLNLDSI:
TEST YEAR: NEW INSTALL REBUILD f -
(CIRC'LE ONE) *PERMIT 'PERMIT REQUIRED — - - ANNUAL TEST
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INSTALL DATE: LAST OVERHAUL DATE: TEST DATE:
MM/Du1YY EMM/DD/YY] _ I (MM/DD/YYj
TESTING INFORMATION * "DEVICE MUST BE PROPERLY TAGGED AFTER TEST
IRRIGATION SYSTEM TESTING TO BE r
COMPLETED YEARLY IN SPRING ONLY
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TEST BEFORE REPAIRS
- FINAL TEST - — -1 1
REPAIR/REPLACEMENT INFORMATION * * *Please read and follow instructions carefully * * *
DESCRIBE REPAIR: SIF EXISTING VALVE IS REPLACED, INDICATE SERIAL NUMBER OF DEVICE REMOVED AND SERIAL NUMBER
OF DEVICE INSTALLED). ALL REPLACED PARTS MUST BE LEFT ON SITE FOR FINAL PLUMBING INSPECTION. PERMIT
APPLICATION AVAILABLE ONLINE AT CLMAPLEGROVEMN.GOV OR 763-494-6060.
COMPANY/TESTER INFORMATION
TEST DONE BY: {PRINT FIRST&�ILAST NAME)
CO PANY NAME: J,)hvl kd n
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COMPANY ADDRESS INCLUDING CITY, STATE, ZIP
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CERTTFICATION NUMBER:
COMPANY/TBSTER PHONE:
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COMPANY/CONTRACTOR FAX
CONTRACTOR LICENSE#
NEW SERIALM