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1940 Cliff Lake Rd - RPZ Test Results.-)t ka t 1 COMME1wtRL MaLWIPAININIMIG & OBEi1'B'®!Nli REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT 24428 Greenway Avenue Forest Lake, MN 55025 (651) 464-2988 NAME OF BUILDING, OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER ADDRESS ,- k CIA- m_,) -C ( 1....._..�:: C TY SAE i ZI` cCOpt N.. 1 APPLICANT COMPANY NAME Commercial Plumbing & Heating, Inc. CONTRACTOR LICENSE # PC643117 CONTACT NAME AND PHONE NUMBER Melinda Wisgerhof ADDRESS 24428 Greenway Ave CITY Forest Lake STATE MN ZIP CODE 55025 EMAIL mwisgerhof@cpandh.com TESTER NAME Joel Parent TESTER CERTIFICATION # BF066231 PHONE 651-464-2988 TEST EQUIPMENT MANUFACTURER Midwest Instrument TEST EQUIPMENT MODEL# 845-5- TEST EQUIPMENT SERIAL# 11150354 TESTING EQUIPMENT CALIBRATION DATE 3/1/21 Static PSI TYPE OF WORK AND FEE INFORMATION (check one) _Install _Relocate _Remove _Replace and SN# of Replaced Device I i L('ttm-) Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _Reduced Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection _Double Check Valve Double Check Detector Fire Protection" Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manufacturer: l S,._ :..-) Model # %5 'y; 1 q � rial # � )t , Size: (inches) System Serviced "'ulr 1 C`f t Location in bldg. L '..LL' Floor # Room # TEST RESULTS: Pass Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) -TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight _Yes _No Closed Tight _Yes _No Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Opened at _psid Final Test Closed Tight _Yes _No Closed Tight _Yes No — Closed Tight _Yes _No Pressure Drop Across Check Valve #1_psid Opened at psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes No psid Closed Tight Yes _No psid Closed Tight Yes _No Final Test Closed Tight _Yes _No psid Closed Tight Yes _No psid Closed Tight _Yes _No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open NO Closed Tight YES NO Closed Tight YES NO Pressure Drop Across Check Valve #1 _YES Opened at psid Final Test Opened at, psid Closed Tight X YES NO "t ` r} -- Closed Tight 'X YES NO Pressure Drop Across Check Valve #1 Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that the tested device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. {) f TESTER'S SIGNATURE: L "C t 1 (3, w —1 TEST DATE: () 1ct 24428 Greenway Avenue  Forest Lake, MN 55025  (651) 464‐2988 REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT   APPLICANT COMPANY NAME  ADDRESS  TESTER NAME  TEST EQUIPMENT MANUFACTURER  STATE  CONTRACTOR LICENSE #  CITY  CONTACT NAME AND PHONE NUMBER  EMAIL ZIP CODE  PHONE TESTER CERTIFICATION #  TESTING EQUIPMENT CALIBRATION DATE TEST EQUIPMENT SERIAL# TEST EQUIPMENT MODEL#  TYPE OF WORK AND FEE INFORMATION (check one)    Install       Relocate     Remove       Replace and SN# of Replaced Device    Rebuild      Test  BACKFLOW ASSEMBLY DETAIL INFORMATION  Type (check one):     Reduced Pressure Principal or Pressure Principal Fire Protection   Reduced Pressure Detector Fire Protection     Double Check Valve        Double Check Detector Fire Protection        Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker  Manufacturer: Model #  Serial #  Size:  (inches)  System Serviced Location in bldg. Floor #   Room #  NAME OF BUILDING, OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER  ADDRESS CITY STATE ZIP CODE  TEST RESULTS:            Pass         Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW)  Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) – TEST RESULTS  Pressure Differential  Relief Valve Check Valve #1 Shutoff Valve #2 Check Valve #2  Final  Test  Initial  Test  Opened            psid  Opened            psid  Closed Tight          Yes          No  Pressure Drop Across       Check Valve #1            psid  Closed Tight          Yes          No  Pressure Drop Across       Check Valve #1             psid  Closed Tight         Yes        No  Closed Tight         Yes        No  Closed Tight          Yes          No  Closed Tight          Yes          No  Double Check Valve or Double Check Detector Fire Protection (DC) – TEST RESULTS  Final Test  Initial Test Closed Tight          Yes          No             psid  Check Valve #1  Closed Tight           Yes         No             psid Closed Tight          Yes          No             psid  Closed Tight          Yes         No              psid  Shutoff Valve #2  Closed Tight            Yes            No  Closed Tight            Yes            No  Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) – TEST RESULTS  Air Inlet Valve  Check Valve #2  Check Valve Shutoff #2  Initial Test  Final Test  Failed to Open     YES     NO  Opened at   psid  Closed Tight   YES    NO  Closed Tight   YES    NO  Closed Tight   YES   NO  Pressure Drop Across     Check Valve #1  Closed Tight   YES   NO  Pressure Drop Across     Check Valve #1  Opened at   psid  Describe parts and repairs when needed:  CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that the tested device is functioning in compliance with  State of Minnesota Plumbing Code, Chapter 4714. TESTER’S SIGNATURE:      TEST DATE: Static Line Pressure: