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11.26.18
DEC/12/2018/WED 10: 45 ASI CORPORATE MECHANICAL FAX No, 7635333464 P, 002/002 BUILDIN 'IN PE TIONS 6431 University.Ave NE Fridley, MN 55432 IWOF Fhoue (763) 572-3604 FPJDLLY Fax (763) 502-4977 BACKFLOW PREVENTER TEST REPORT Instructions to CeVffied Testers: All information must Ire typed or printed clearly in buck ink, SITE ADDRESS: 2 0 S )~RMLEV,MN ZIP CODE: e� OWNER/TENANT: n /, DATE: /J k TELEPHONE: MADE MODEL: LjJh,,s 9`� SJZE: SERIAL Nlr M19ER: 'j LOCATION OF DEVICE: ,1,. � LONEW/OVFRfUULED LE TEST NEAR I ❑ TEST YEAR 2 ❑ TLST YEAR 3 ❑ TUST YEAlR 4 cz-Tcx vA1.vE ezEcK vVALVEFRES DIF lames DIF WHEN 01 42 A CROSS 01 REL EF OPIWS ST P AIN.8 z COCK TEST U Leaked ❑ Leaked ❑ None BEFORE REPAIRS Li Closed © Closed psi psi ❑ CLND TEST Closed C7 Closed — ps, _CL., o psi DESCRIBE REPAIR: NOTE WHEN RE,PLACING/RWOWNG Alk'RPZ,PROVIDE.SERIAL]UMBER QZ RPZ BEING RIC,PLACEARMOVF'D CERTIFICATION-. I hereby cel tify the foregoing datato be couect and tiaat tfie tested devise is fuuctiolxi)xg within the litnits of the standards. PI-Qmbing Coiapazay: Add:rass; Cextifled By: M Certificationl�- (signature) OFFICE USE ONLY, RECEIVED-, ❑ ENTERED