7.10.19 0711812019 15:08 Outdoor Images, Inc TAX)6514802008 P.0011001
BUILDING INSPECTIONS
6431 University Ave NE
Fridley, MST 55432
Phone (763) 572-3604
F %. % Fax 763 502-4977
BACKIFLOW PREVENTER TEST REPORT
Instructions to Certified Testers: All information must be typed or printed clearly in black ink.
SITE ADDRESS: b,c ,.C, "7 FRIDLEY MN ZIP CODE:
OWNER/TENANT: DATE: -1 `L TELEPHONE:
MAKE&MODEL; J�1' ' r { SIZE: i , ISERUL NUMBER.--31 "X
VOCATION OF DEVICE: 'n /
❑NEVV/O'V•il+RHA.LTX L,D ❑ TEST YEAR I ❑ TEST YEAR 2 ❑ TEST YEAR 3 1 ❑ TEST YEAR 4
CHECK'VALVE CHECKVALVE PRES DIP PRES DIF WHEN
#] 02 ACROSS#1 RELIEF OPENS STRAINER
CHECK
TEST ❑ Leaked ❑ Leaked psi si ❑ None
BEFORE REPAIRS - p
�� Closed '�Closed ❑ CLND
FINAL ❑ Leaked ❑ Leaked
TEST ❑ Closed ❑ Closed
— psi psi
DESCRIBE
REPAIR:
* NOTE:WHEN REPLACINGMEMO'V]'NG AN RPZ,FROV IODE SERIAL NUMBER OF RPZ BEING REPLACEDMEMOVL,1)
CERTIFICATION:
I hereby certify the foregoing data to be correct and that the tested devise is functioning within the Iimits of the
standards.
Plumbing Company: Address:
Certified By: — Certification##: 67 , Phone#: ►;j
(signature) -
OFFICE USE ONLY:
RECEIVED: ❑ ENTERED