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mechanical contractors, inc.
1257 Marschall Road, P.O. Box 237 · Shakopee, MN 55379
Phone: 952/445-5100 Fax: 952/445-5119
BACKFLOW PREVENTOR (RPZ) TEST REPORT
JOB ADDRESS: 3~t3 /(/1/dWI'lOd _~ ~~_~K ,/HAl
OWNER/OCCUPANT/CONTACT PERSON: JIb, . /
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CONTACT PHONE:
DEVICE LOCATION: ~rf. C!I!?H d"'/S"~~/"~;/~
SERVES WHAT SYSTEM: L "'-U/ d //fi~~ /J
MAKE:~y~." S' - . MOD~Llll: f?~L,
FLOOR I:
I ROOM Ill:
SIZE:
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. SERIAL ';;//8'39;Z ~
INSTALL DATE (MONTHlDAYIYEAR):
OVERHAUL DATE (MONTHIDAYIYEAR):
TEST DATE (MONTHlDAYIYEAR):
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6 -;;'3 - II
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Ii CHECK VALVE
PSUDIFF
RELIEF
PSIIDIFF
t2 CHECK VALVE
TEST BEFORE REPAIRS
krL/
.7. ?
or
FINAL TEST
DESCRIBE REPAIR IF ANY:
TEST DONE BY (PLEASE PRINT FIRST & LAST NAME):
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CERTIFICATION NUMBER: / r..52? /
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I COMPANY NAME:
I COMPANY ADDRESS:
I CITY:
STATE:
ZIP:
CONTRACTOR UCENSE t:
COMPANY PHONE Ill:
CONTACT PER80NlPHONEIll: