1950 Cliff Lake Rd - RPZ Test Reportsf 3P)L1
REDUCED PNESSUNE BACYFLU" PNEVEIdTEP. TEST REPORT
AND TESTABLE DOUBLE CHEGKS
Service Name: �����`too
Address: C
VON
Device Location. a
Account # ,_
Type:ONO ON III
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Install Date:
Qate:
Contract Person./Tele.
state 6!1` Zip:e
Serve what system: j
Serial # 0
Make: �_._.,;,.w�� Madel. �"� �� •.,�.
Size:
Air Gap installation Date:
Test Qate;
` 1 Aiinraal Check Valve #1 Check Valve #2 Differential Pressure Relief Valve
ReNo
poft• Pressured Pressure Opened at psid reduced pressure
Did not open
Repairs:
( ", ` • )Sign and date Tag
The above is certified correct. Signed
Tested by (Print Name) Chris Theisen
ORPORAXE
MECHANICAL
5114 Hillsboro Avenue North
1Jew Hope, MN 5542E
Phone:(763) 533-3070
Fax (763)533-3464
066265
Certification Number '