HomeMy WebLinkAboutBackflow Report 3/10/2011 (2) ETR OTESTINO
31222 Cedar Creek Road
Hinckley, MN 55037
Office: (612) 221 -5888
Backflow Preventer Rebuild & Test Report
Busi d� S �1�
ness: It..7c'J � � i f'ontactPerson /Tel.: Date:
S et 1 J : 7, J 3- /D -//
address: C' it∎: Zi
15 860 t- A./ Poi � I ?� S I �z , old � Ake._ Mahe: _, � �-
Make: Model: Size: 3/ Serial #:
c J4rrs
909 c ..T �(0 5 n a
Location of Device: Sery -d hat Svst "u):
/ oofiR /Zoom �3o,�tr2
Rebuild Date:
(5 yr. = Overhaul/Rebuild)
Test Yr. Check Valve #1 Check Valve #2 Differential Pressure Relief
(Circle One) Leaked( ) Closed ( Leaked( ) Closed (X) Did Not Open 1
2 3 4 5
Pressure : 7.0 Pressure : 6' 6 Opened At: (:)
Cleaned Cleaned Cleaned
�+ Replaced Replaced Replaced
Poppet Poppet Poppet
P Spring Spring Spring
A 0 Ring 0 Ring 0 Ring
Rubber Seat Rubber Seat Rubber Seat
j Other Repairs Other Repairs Other Repairs
R
S
Certification
I hereby certify the foregoing data to be correct and th t the device tested is functioning
Within the limits of the standards - /C-
Signed: Dated:
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.