EA189231 RPZ ReportCITY OF EAGAN
MANDATORY INSPECTION OF BACKFLOW PREVENTER
Test Reduced Pressure Zone Backflow Preventer
Unit ID (Account #) I
I PROPERTY I ADDRESS I CONTACT PERSON I PHONE #
BACKFLOW PREVENTER INFORMATION
Type
Assembly
Serial Number
Model
Size
Manufacturer
D'7
C
DC [.F- A
i
Responsible Company
Phone #
Date of Last Rebuild
Next Scheduled Rebuild
Device Location
Device Serves What System
pan vtc-f ovtry
BACKFLOW PREVENTER ASSEMBLY TEST
Check Valve I O Leaked (v - Cl se Tight
Check Valve 2 () Leaked (used Tight
Press Diff Across Check Valve #1 , Z PSI
Press Diff Across Check Valve #2
Press Diff Relief Open
Describe Repairs
PSI
PSI
I hereby certify the forgoing data to be correct and that the tested device
is functioning within the limits of the standards.
Firm Name: Northland Mechanical Contractors, Inc.
License Number 059225-PM
Test By:
Signature
Printed Name: Mike Calverley
nt
C4New Install ( ) Test ( ) Rebuild
Address: 9001 Science Center Drive
New Hope, Minnesota 55428
Certification #: BF708175
Date Tested: Z/ S' / Zv Z54
( ) Replaced Unit
PLUMBING PERMIT IS REQUIRED FOR ALL REPAIRS AND REBUILDS
Date Copy to City