RPZ 06.27.2019 Jul, 25. 2019 11 , 10RM No, 0403 F. 1
(JAW BUILDING INSPECTIONS
6431 University Ave NE
Fridley, MN 55432
CITYOF Phone (763) 572-3604
FlDL Fax (763) 502-4977
BACKFLOW PREVENTER TEST-REPORT
Instructions to Certified Testers:All information must be typed or printed clearly in black ink.
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SITE ADDRESS: l Z-50 -12-nd fjVf, g tF F'RIDLEY MN I ZIP CODE: a
OWNER/TENANT: DATE: I TELEPHONE:W,221-LiS0
MAKE &MODEL- cc �l SIZE: ' SERIAL 1�IC MBF-R: IS 1
LOCATION OF DEVICE_ UI\Z r i
❑NEW/OVERHAULED iftEST YEAR 1 ❑ TEST YEAR 2 1 ❑ TEST YEAR 3 1 ❑ TESTY AI 4
CHECK VALVE CHECK VALVE PRES DIF PRES DIF WHEN
#1 92 ACROSS#1 RELIEF OPENS STRAINER
CHECK
TEST ❑ Leaked ❑ Leaked ❑ None
BEFORE REPAIRS ❑ Closed 0 Closed -psi psi ❑ CLND
FINAL ❑ Leaked 0 Leaked
TEST Z-Closed ,,O Closed 'si psi iD� �I I 1
DESCRIBE
REPAIR: " 1 5
* NOTE. WHEN REPLACING/REMOVING AN RPZ,PROVIDE SERIAL NUMBER OF RPZ BEING REPLACED/REMOVED
CERTIFICATION:
I hereby certify the foregoing data to be correct and that the tested devise is functioning within the limits of the
standards_
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PWm ing Company: Address: S7-1I2-
Certified By: Certification 4A,55E ` 0kO Phone# -. W `Sa;2-3 f 9
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OFFICE USE ONLY:
RECEIVED_ ❑ ENTERED
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