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3380 Central Park Village Dr - RPZ Test Results)W1 7 !S\ REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT 24428 Greenway Avenue Forest Lake, MN 55025 (651) 464-2988 NAME OF BUILD G, OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER 1 c- , 2-L L� ' t_ ADDRESS CITY S ATE ZIP CODE APPLICANT COMPANY NAME CONTRACTOR LICENSE # CONTA T NAME AND PHONE NUMBER Commercial Plumbing & Heating, Inc. PC643117 Melinda Wisgerhof. ADDRESS CITY STATE ZIP CODE EMAIL 24428 Greenway Ave Forest Lake MN 55025 mwisgerhof@cpandh.com TESTER NAME TESTER CERTIFICATION # PHONE Ben Theis BF064401 612-834-2743 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE Wilkins TG-3 6)9150677 3/13/20 TYPE OF WORK AND FEE INFORMATION (check one) _Install _Relocate _Remove Replace and SN# of Replaced Device r J-%\ 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 # -( fk N12 5Terial #rgb7 j Size: (inches) \\� -- V System Serviced � �(I 1— \J� Location in bldd� P\ng1 ((``LL\nl oor# 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 Closed Tight Closed Tight _Yes No Opened at Test _Yes _No _Yes _No pressure Drop Across Check Valve #1 psid _psid Final Closed Tight �( Closed TightlC Yes No Closed Tight �Yes_No � 4ro . Opened at Test _Yes _No pressure Drop Across Check Valve #1 psid _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 Soill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Checl< 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: 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.Y'-� TESTER'S SIGNATURE: TEST DATE: 24428 Greenway Avenue Forest Lake, MN 55025 (651) 464-2988 REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT NAME OF BUILD�jG, OWN R/OCCUPANT CONTACT NAME AND PHONE NUMBER ADDRESS CITY s.. { C - STATE N/ ZIP CODE APPLICANT COMPANY NAME CONTRACTOR LICENSE # CONTA T NAME AND PHONE NUMBER Commercial Plumbing & Heating, Inc. PC643117 Melinda Wisgerhof ADDRESS CITY STATE ZIP CODE EMAIL 24428 Greenway Ave Forest Lake MN 55025 mwisgerhof@cpandh.com TESTER NAME TESTER CERTIFICATION # PHONE Ben Theis BF064401 612-834-2743 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE Wilkins TG-3 D9150677 3/13/20 TYPE OF WORK AND FEE INFORMATION (check one) _Install _Relocate _Remove Replace and SN# of Replaced Device j. Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): LReduced 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: \K Na, Model # k P(%)( (V1!:; "'ierial # Size: 3 (inches) System Serviced V� Location in bldgV--�?n1� L\ni oor # 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 Closed Tight Closed Tight _Yes No Opened at Test _Yes _No _Yes _No Pressure Drop Across Check Valve #1_psid _psid Final Closed Tight es Closed Tight Yes No Closed Tight Yes No 40 Opened at Test _ _No Pressure Drop Across Check Valve #1l_psid _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: 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. 55 , TESTER'S SIGNATURE: TEST DATE: a "C