HomeMy WebLinkAboutBackflow Report 5/3/2011 R0
TES TIN C
31222 Cedar Creek Road
Hinckley, MN 55037
Office: (612) 221 -5888
Backflow Preventer Rebuild & Test Report
Business: I c.Ji.) 04/CS 4aa /4 Contact Person /Tel.: Date:
Sc+ l LSD 71c) 5 S - ao��
Address: (it}: Zip: ._ _ — _
/x866 rsH Pa>aT fit) Si. 74,64 l ck� c I --
\1ake: Model: Size: Serial #:
95 -o c) 3
Location of Device: Served what System:
("0A:7-Le 47,t Pt yr) tria. .i >+lt y o b ► fi e s G,o T Io , �
Rebuild Date:
S- 3 -7 o,/
(5`" yr. = Overhaul/Rebuild)
Test Yr. Check Valve #1 Check Valve #2 Differential Pressure Relief
1 2 (Circle e) 4 C) Leaked( ) Closed (Y) Leaked( ) Closed ()() Did Not Open t 1
3 (\ Pressure : Pressure : 2,0 Opened At: 3 .
Cleaned Cleaned Cleaned
E enlaced Replaced Replaced
Poppet Poppet Poppet
P Spring Spring Spring
A O Ring O Ring O Ring
Rubber Seat Rubber Seat Rubber Seat
j Other Repairs Other Repairs Other Repairs
R CNEc. /
S
Certification
I hereby certify the foregoing data to be correct and at the device tested is functioning
Within the limits of the standards
Signed: Dated: S "-°)
Tested By : GARY FORD Certification # 058476 -BF or COLE FORD Certification # 66445 -BF
F i rm Name: Metro Testing Address : 31222 Cedar Creek Rd. Hinckley, MN 55037
This report is for the purposes /Recording only; Owner is responsible for safe operation
And upkeep of scheduled maintenance.