1247 Northwood Pkwy - RPZ Test Reports5&.53 LI) D
CRMMERCIAL
PIgMBlg6 6 NEq)r/M6
24428 Greenway Avenue
Forest Lake, MN 55025
(651)464-2988
�c��wltuBACKFLOWASSEMBLY RBA TEST REPORT
NAME OFB ILDING,OWNER/OCCUPANT
(j CONTACTNAMEAND PHONE NUMBER
ADDRESS I �/i / a /4� 1"
..CC �I/e �QQJS Ik CITY STATE / ZIP CODE
1` S51.2
APPLICANT COMPANY NAME
CONTRACTOR LICENSE# CONTACT NAME AND PHONE NUMBER
ADDRESS CITY
STATE ZIP CODE EMAIL
TESTER NAME _ --I G( rE!/tT TE F�,C��rR+TFICATION PHONE
�1 06623
TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE
TYPE OF WORK AND FEE INFORMATION (check one)
_Install _Relocate _Remove _Replace and SN# of Replaced De is �6Sz 63 X
-Rebuild st
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 ProtectioxPressure Vacuum Breaker —Spill Resistant Pressure Vacuum Breaker
Manufacturer: --{— N, . %
I Model # z0,I��Seriaall # 1 OOkJ 1 ci.5 Size: z `c (inches)
System Serviced—1—rr;; a j'fOA. Location in bldg. t /AS'i Floor # Room #
TEST RESULTS: ❑Pass ❑Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW(
Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) —TEST RESULTS
Pressure Differential
Check Valve #2
Shutoff Valve #2
Check Valve #1
Relief Valve
K
d Tight _Yes No
Closed Tight_Yes_No
Closed Tight _Yes_No
pressure Drop Across Check Valve #1_psid
Opened at_psid
Closed Tight —Yes —No
Openedat _psid
d Tight _Yes No
Closed Tight_Yes _No
Pressure Drop Across Check Valve#1_psid
Double Check Valve or Double cnecR ue7ec7Dr nre rrr,.C�.r.,rr r.,.,r -----
Valve #1
Check Valve #2 Shutoff Valve#2
Check
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 (SRVBI -TEST RESULTS
Check Valve
Air Inlet Valve Shutoff YES_NO
Initial Test Failed to Open _YES_NO
Closed Tight _YES_NO Closed Tight_
Opened atPsid Pressure Drop Across Check Valve#1p
Closed Tight XYES_NO p Closed Tight.YES_NO
Final Test Opened at r Psld Pressure Drop Across Check Valve#1
Dascribe parts and repairs when needed: (.t/�if/!d /v i y me om ipianc ewith
CERTIFICATION:( hereby certifytheforegoinginfor Y r Idedb to be correct and that the te�ddeviceis functioning inc
State of Minnesota Plumbing Cade, Chapter 47 TEST DATE:�c-
TESTER'S SIGNATURE: