Cub foods Eagan East 2023 1324428 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: