RPZ Testing ReportBACKFLOW PREVENTER TEST REPORT
Instructions to Certified Testers: All information must be typed or printed clearly in black ink.
SITE ADDRESS: FRIDLEY, MN ZIP CODE:
OWNER/TENANT:DATE: TELEPHONE:
MAKE & MODEL: SIZE: SERIAL NUMBER:
LOCATION OF DEVICE:
□NEW/OVERHAULED □TEST YEAR 1 □TEST YEAR 2 □TEST YEAR 3 □TEST YEAR 4
CHECK VALVE
#1
CHECK VALVE
#2
PRES DIF
ACROSS #1
CHECK
PRES DIF WHEN
RELIEF OPENS STRAINER
TEST
BEFORE REPAIRS
□Leaked
□Closed
□Leaked
□Closed _________psi _________psi □None
□CLND
FINAL
TEST
□Leaked
□Closed
□Leaked
□Closed _________psi _________psi
DESCRIBE
REPAIR: _________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
*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.
______________________________________________________________________________
Plumbing Company:Address:
Certified By: ____________________________ Certification #: _______________ Phone #: _____________
(signature)
OFFICE USE ONLY:
RECEIVED: _________________________________□ENTERED
BUILDING
INSPECTIONS 7071 University Ave NE
Fridley, MN 55432
Phone (763) 572-3604
Fax (763) 502-4977