Loading...
1439 Lone Oak Rd -RPZ Report Results/+L (I'MYlI /1IG G fME,q T/NG 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