HomeMy WebLinkAbout2013-03-20 Roto Rooter RPZ Test Report 99 5th Avenue NW, Ste. 200 .''` ` ." '; ow Now Brigton, MN 55112 Invoice # 1) 0 0 3 0
';:" s1 ,"° dr e 651- 633 -.9990 Fax: 651 -630 -9997
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REDUCED PRESSURE BACKFLOW PREVENTER, TEST REPORT
Service Name; ,•,�,,, e,•^
Y S 7AL. 4- o•tifo S Contact Person /Tele: �c_ `!
Cit J ,P ez 144 S State: r►�•n Zip: ,SJo 8
/Address: ( -101 ,.5.+- G� ■ x T ^ `— y� pp "
,� -> (9 Serve what system: {i'.'` -Y -'`of t
Device Location: t,�.,�� S
Account Serial Number: NO il 2 S"]
Type: g, -z Make: g.--)' ilk-. . ^ SModel: _' ?S X k. Size: 31
Rebuild Due Date: 2 c L .3 Test Date' 3 - 2 0 -. 1. 3
Annual Check Valve #1 Check Valve #2 Differential Pressure Relief Valve
Report Pressure 0. Pressure 4 'T Opened at 3 • A. psi
Did not open
. ❑ Cleaned 1:7 Cleaned ❑ Cleaned
❑ Replaced ❑ Replaced ❑ Replaced
R ❑ Disc ❑ Disc 0 Disc
E ❑ Spring ❑ Spring ❑ Spring
P ❑ Guide Li . Guide ❑ Guide .
A 0 Pin Retainer ❑ Pin Retainer ❑ Diaphragm, Large
I ❑ Hinge Pin ❑ • Hinge Pin 0 Lower
.R 0 Seat ❑ Seat ❑ Upper
S ❑ Diaphragm ❑ Diaphragm ❑ Diaphragm, Small
❑ Other, describe ❑ Other, describe ❑ Lower
M Ie.e.,,.. ,.-yb c ., e.,✓ / ./4 -'~ ❑ Upper
O Spacer, Lower
❑ Other, describe
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(:_.9e ) Sign and date tag
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The above is certified correct. Signed C.- -----
D Tested: 3
Tested by (Print Name) 7G4 c'• fi 5 " ) "" 2-- Certification # 0 fo 4 161 6 i'
License #p &/l G fonr
Permit Fee: $
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