HomeMy WebLinkAbout2020-08-07 Backflow Preventer Test Report & Service Order - Harris MechanicalBACKFLOW PREVENTER TEST REPORT
JnUI HARRIS
Address City Zip
606(o(OSGca�� A��. C���k�a�k (ae-'��� 5.
HARRIS
Make Device of and Model ice Size
t,�. i '-'-17 -)U--1
909 Montreal Circle
:]Mmber
17-1 H
St. Paul, Minnesota 55102
Location of Device 70 _
651.602.6606
JnUI HARRIS
Address City Zip
606(o(OSGca�� A��. C���k�a�k (ae-'��� 5.
Ower Telephone No. Date
i -)A
Make Device of and Model ice Size
t,�. i '-'-17 -)U--1
r1 Serial No.
I
le- 'X6
Location of Device 70 _
Check Valve k1
Check Valve H2
Pressure Differential
Across #1
Pressure Differential
when Relief Opens
Strainer
Test Before
Leaked �
Leaked
None
Repair
Closed
Closed �
P.S.I.
P.S.I.
CleanedEQj
/a'[ -C)
Repair
Final Test
Leaked �
Leaked
P.S.I.
P.S.I.
Closed �
Closed
(.r CJ
�
Cleaned E;j
Cleaned EQj
Cleaned E;;k
Comments/Materials Used:
Replaced:
Replaced:
Replaced:
Disc
Disc
Disc:
Spring IL
Spring
Upper
Guide EQj
Guide ESQ,
Lower
Pin Retainer EQj
Pin Retainer E;;6
Spring Q
m
Hinge Retainer
�
Hinge Retainer
�
Diaphragm: �
i
Seat E�7d
Seat
Large: [�{.
a
R
'a
Diaphragm EQj
Diaphragm E;�j
Upper EQj
rc
1;j
E;j
Lower EQj
Small EQj
Seat: EQj
Upper
Lower
Spacer:
Lower
Final Test
Closed Tight �
Closed Tight
Opened at + bs
Reducetl Pressure
The abov a orti certified to be true, Certification Number D(aY Z 1 tet'
Initial Test By Representing
Repaired By / Representing
Final Test By / Representing
White - City
Yellow - Customer
Date - I -2
��6
Pink - File
HC -1008
CINTA Io
READY FOR THE WORKDAY'
Service Order
Repair - Backflow Service
Tech Clock IN/OUT IVR 844-347-3487 IVR# 161927
Service Location:
Service Order No:
Vendor ID:
Walgreens 06916
6061 OSGOOD AVE N
S2004081585 - 3
harrismech
OAK PARK HEIGHTS, MN 55082
Customer PO:
Schedule Date:
Complete By:
Phone#(651)689-0046 Fax#
Requested by:
57066861
8/19/2020
Service Results Required
Technician Work Performed: Check all that apply Y N
—i
Date Time In Time Out Of Techs Repair Successfully Completed? (�
Deficiencies Found?
System Tagged Compliant
System Red Tagged
Additional Work Authorization Call 866-246-8273
Cintas Authorizing Agent Name
Comments:
'�P-�o,JJ ?-VZ, Lv,\ K—j 9 7511L leA 46639 i
,2 tGv_ nu ham; T Z o Z6
Technician lignsture Route Print Name Date
My signature represents and warrants that I have personally performed the inspection andror work specified in this Service Order, supplied the parts
indicated above (if any), and notified the customer of deficiencies (if applicable). / hereby certify and warrant that off work was performed in full compliance
with all applicable laws, rules, and regulations, including (but not limited to) all local authority having jurisdiction rules and/or requirements, NFPA and/or
building code requirements, and local licensing and/or permitting requirements. I further certify and warrant that I and any other technicians who performed
the work are properly trained, certified, and licensed to perform the work in the given jurisdiction.
Customer Acknowledgement '
l hereb nowledge the satisfactory completion of the above stated work. Store Stamp
�o Z
Ant01,,dSignature
Print Name Title Date
My signature indicates that I have reviewed and approved all work done by this technician, and I am satisfied with the work done and the final condition of
my facility with the respect to the scope of work
Cintas 866.246-8273
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60619sgooJA,
OIkPark Heighis
.Y
-'82