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3275 Dodd Rd RPZ ReportBACKFLOW PREVENTER TEST REPORT JOB ADDRESS (INCLUDE ADDRESS #, STREET NAME, &DIRECTIONAL), Apt/Unit # System BACKfLOiAI A55EM8LY INfORMATfiG1iV (Ail Fields are Served: �Sh � �-�1. Manufacturer of Assembly: � • � � � ►'L �� VOSS UTILITY & PLUMBING {763) 497-4577 OFF (763) 497-3994 FAX (612) 867-3009 CELL !'!� Model # �` � � � �— I ``\\ Size of Assembly: � Z Serial # �� I'�c C1 �n�� �© Location of Assembly: Floor # � S � Room # ��—"' Date test was performed:�� a� Reduced Pressure Principle Backfiow Prever�ter (RPj —TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Closed Tight _-Na Initial Test Closed Tight _Yes _No Closed Tight Yes No — — _Yes Pressure Drop Across Opened at psid Check Valve #1 psid Describe parts and repairs when needed Final Test Closed Tight �( Yes _No 7-` Closed Tight -� Yes _No Closed Tight _Yes _No Pressure Drop Across Opened at psid Check Valve #1�psid [Sntrllalp [heck Backflnw Preverrtian Assembly (DCa —TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Closed Tight _Yes _No Closed Tight _Yes _No Closed Tight _Yes _No Initial Test psid psid Describe parts and repairs when needed Closed Tight _Yes _No Closed Tight _Yes _No Closed Tight _Yes _No Final Test psid psid Pressure Vacuurr>I Breaker Assembly (PVBj or Spin Resistant_ Vacuum Breaker (SRVB} —TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Failed to Open_ Yes _No Closed Tight _Yes _No Closed Tight Yes No Initial Test Pressure Drop Across Opened at psid Check Valve #1 psid Describe parts and repairs when needed Closed Tight _Yes _No Closed Tight Yes No Final Test Opened at psid Pressure Drop Across — — Check Valve #1 psid CERTIFICATION: I certify the foregoing information provided by me to be correct and that the tested device is functioning with the limits of the standards. Name (Print State of MN Date: ��—�i, � �% >: - __