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2103 Silver Bell Rd - Backflow Assembly ReportMartTAnIsk .. .Q3`YfMbY.YR. '.I Y'A r0�_fRtlCT Start To Finish Contracting, Inc. PMOSS85 lynn@ncmg:i.com S707 Excelsior Blvd. St. Louis Park, MN 55416 4: 952.259.1219 R 9S2.836.2403 1 RFGIJI ATFD RAC_Ic1:i-CM AS5FMR1 V (RRA1 TFST RF:PnRT NAME OF BUILDING, OWNEMCCUPANT, CONTACT NAME A[ -JD PHONE NUMBER Install Relocate Remove Replace and. SN# of Replaced Device Rebuild Type (check one): Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection Double Cht ek Valve Double Check Detector Fire Protection Pressure Vacuum Breaker Spill Resistant: ►ressure Vacuum Breaker Manufacturer: WOCIA5 Model #OO Serial # ��� Size: 2 (inches) System Lc cation in bidg arli-4A -i IT) CA Floor # Room # Check valve #2 Shutoff Valve 42 Check vahfe ail Pressure differential Relief Valve Initial Closed Tight yes No Closed Tight Yes No Closed Tight Yes No Opened at psid Test Pressure Drop Across,. Check valve #i psid Final Closed Tight Yes No Closed Tight Yes No Closed Tight Yes No Opened at, psid Test Pressure Drop Across Check valve #1— __ psid Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight Yes No psid Closed Tight Yes No —_psld Closed Tight Yes No Final Test Closed Tight Yes No .._..._Psld Closed Tight Yes No �sld Closed Tight Yes No +"►.�r Inlet Valve Check Valve Shutoff#2 Initial Test Failed to :)pen i Yes U Closed Tight Ye No Closed Tig it Yes No O ened apt sid Pressure Drop Across Check Valve #1 sid Final Test Opened at psid Closed Tight Yes No Pressure DropAcross Check Valve #1 sid Closed Tight Yes Na Describe earts and re airs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be correct a the d d vice Is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. TEMR'S SIGNATURE T>:ST PATE: ,1z ` startTo�r/1^�1 �^�S f,. Start To Finish Contracting, Inc. PM05885 (ynn@ncmgi,com S707 Excelsior Blvd. St. Louis Park, MN 55416 0: 952.259.1219 F: 952.836.2403 REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT COMPUTE JOB ADDRESS (INCLUDE Apt/Unit #) NAME bF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER E RESS c r J srA ,W.r I _j TESTER NAME TESTER CEIMF TEST EQUIP ENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUII I E, CONTgT NAME AND PRONE NUMBER J L '(Z 1 �y �� 4 ZIP AIL �/ 6 f /'ore N # PHONE SERIAL# TESTING EQUIPMENT CALIBRATTI0.1N DATE Mo Yr Install Relocate Remove Re lace and SN# of Replaced Device Rebuild Test �- mom= Type (check one): �educe Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire P1 o'tection Double Check' -Valve Double Check Detector Fire Protection Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manufacturer: Wi-I1'r fj s Model #,^._ ���� -Serial # � �Size: '� —(inches) Caf�J a G � � A location on Bldg 'l�/V M i-d ��J'` Floor #� Raom # System Seralved Check Valve 02 shutoff valve #2 check Vilr #1 Initial Closed Tight Yes No Closed Tight Yes) No Closed TightC-S) No r� Test Pressure Drop Ar-ross Check Valve #1. 5id Final Closed Tight Yes No Closed Tight Yes No Closed Tight Yes No Test Pressure Drop Across Check Valve #1______psid Check Valve #1 Check Valve #2 Initial Test Closed Tit ,,ht Yes No - psid - Closed Tight Yes No psid Final Test Closed Tight Yes. No ----psld Closed Tight Yes No _psid Air Inlet Valve Check Valve Initial Test Failed to Open Yes No Closed Tight Yes No O ened at' sld Pressure Drop Across Check Valve #l�psid Closed Tight Yes No Final Test Opened at psid Pressure DroE Across Check Valve ill sid Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing Information provided by me to be State of Minnesota Plumbing Code, Chapter 4714. t TESTER'S SIGNATURE 1 --Pressure Differential Relief valve Opened at, iPsfd opened at�...psid S'9utoff valve #2 Closed Tig'it Yes No Closed Tigiyt Yes No Shutoff #2 closed Tight Yes No Closed Tight Yes No tested d Ice isfunctioning in compilan a with