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REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT
24428 Greenway Avenue
Forest Lake, MN 55025
(651) 464-2988
NAME OF BUILDING, OWNER/OCCUPANT
CONTACT NAME AND PHONE NUMBER
ADDRESS� 1
�
CITY —
STATE
ZIP CODE
f:
1
APPLICANT COMPANY NAME CONTRACTOR LICENSE #
CONTACT NAME AND PHONE NUMBER
Commercial Plumbing & Heating, Inc. PC643117
Melinda Wisgerhof
ADDRESS
CITY
STATE
ZIP CODE
1
EMAIL
24428 Greenway Ave
Forest Lake
MN
55025
mwisgerhof@cpandh.com
TESTER NAME
TESTER CERTIFICATION #
PHONE
Mike Reinke
48633
651-464-2988
TEST EQUIPMENT MANUFACTURER
TEST EQUIPMENT MODEL#
1845-3
TEST EQUIPMENT SERIAL#
TESTING EQUIPMENT CALIBRATION DATE
Mid -West
'07221850
07/28/22
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 Valv\e_Double Check Detector Fire Protection_Pressure Vacuum Breaker_Spill Resistant Pressure Vacuum Breaker
Manufacturer: LN aj `` _) Model # LF! 19 LSerial # \ S Size: (inches)
System Serviced c�h ��Q ��'1P ,(/ Location in bldg. Floor # Room #
TEST RESULTS: 0 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 TightLYes
Closed Tight Yes
Closed Tight'X,Yes No , O
L
Opened at_psid
Test
_No
_No
Pressure Drop Across Check Valve #1_psid
Final
Closed Tight
Test
Closed Tight _Yes _No
Closed Tight _Yes _No
_Yes _No
Pressure Drop Across Check Valve #1_psid
Opened at _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.
TESTER'S SIGNATURE:. n]- 2 (1 E C t TEST DATE: V