HomeMy WebLinkAboutBACKFLOW PREVENTER TEST 12/20/2016 REDUCED PRESSURE BACKFLOV/ PREVENTER TEST REPORT
AND TESTABLE DOUBLE CHECKS
Service Name: U5 (,vot< Contract Person/Tele:
Address: 15$30 r-r- nk.d-iy+/1 -reezil City: Prior L' ..ke,
State:1 ry Zip: S537a
Device Location: Opfer- ry1Pdn rmrr, Serve what system: ;ter I7I1
Account# Serial# )(1-4913
Type: 1 PZ
Install Date: Make: Ore- le> Model:qQ D/7-2
Size: 3/y
Air Gap Installation Date:
NEW/OVERHAULED ❑ Test Year 1 ❑ Test Year 2 ❑ I Test Year 3 ❑ I Test Year 4 ❑ I
Rebuild Date: Test Date: /3-ao-0.or6
Annual Check Valve#1 Check Valve#2 'Differential Pressure Relief Valve
Report Pressure S.49 Pressure d.0 Opened at2.1 psid reduced pressure
Did not open
Repairs:
( X )Sign and date Tag ,..-- �, �/
The above is certified correct. Signed 0. ., -:5%--. Date tested 1?•AO-a1e,
Tested by(Print Name) --ir:xcn 1r I5t'1A Certification Number f '/ 7
CORPORATE
MECHANICAL
5114 Hillsboro Avenue North
New Hope, MN 55428
Phone:(763) 533-3070
Fax (763)533-3464