2140 Cliff Rd - RPZ Testcj A )CO o
24428 Greenway Avenue
Forest Lake, MN 55025
(651) 464-2988
REGULATED BACKFLOW ASSEMBLY tMDAI TEST REPORT
NAME OF BUILDING, OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
r
d
APPLICANT COMPANY NAME
CONTRACTOR LIC 4SE #
CONTACT NAME AND PHONE NUMBER
Commercial Plumbing & Heating, Inc.
PC643117
Melinda Wisgerhof
ADDRESS
CITY
STATE
ZIP CODE
TEMAIL
24428 Greenway Ave
Forest Lake
MN
55025
mwisgerhof@cpandh.com
TESTER NAME
TESTER CERTIFICATION #
PHONE
Joel Parent
BF066231
651-464-2988
TEST EQUIPMENT MANUFACTURER
TEST EQUIPMENT MODEL#
TEST EQUIPMENT SERIAL#
TESTING EQUIPMENT CALIBRATION DATE
Midwest Instrument
845-5-
11150354
3/1/21
Static �� PSI TYPE OF WORK AND FEE INFORMATION (check one)
_Install _Relocate _Remove _Replace and SN# of Replaced Device t)bl L p
Rebuild Test
BACKFLOW ASSEMBLY DETAIL INFORMATION
Type (check one): -Reduced Pressure Principal or Pressure Principal Fire Protection Pressure Detector Fire Protection
_Reduced
_Double Check Valve_Double Check Detector Fire ProtectionPressure Vacuum Breaker_Spill Resistant Pressure Vacuum Breaker
Manufacturer:1, Model# ����1__Serial#/�(` Imo,Size: 2 (inches)
—5�'\/�y1Y\
System Serviced 11(Y lG� �� ��� Location in bldg. 1�'(1Q1r Y'MYMFloor # 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
Initial
Closed Tight No
Test
Closed Tight _Yes _No
Closed Tight _Yes No
_Yes
Pressure Drop Across Check Valve #1_psid
Opened at _psid
Final
Closed Tight Yes
Closed Tight*Yes
Closed Tight (Yes _No
Opened at psid
Test
_No
_No
Pressure Drop Across Check Valve #1_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 _YES NO
Closed Tight YES NO
Closed Tight YES NO
Opened at psid
Pressure Drop Across Check Valve #1
Final Test
Opened at psid
Closed Tight YES NO
Closed Tight YES NO
Pressure Drop Across Check Valve #1
Describe parts and repairs when needed: P
CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that the tested device is functioning in complia ce wi
State of Minnesota Plumbing Code, Chapter 4714.
_
`
TESTER'S SIGNATURE: TEST DATE: