HomeMy WebLinkAbout2017-08-02 Sumit Fire Protection Backflow Preventer Inspection Form ,eAr
Form for Inspection,Testingand Maintenance of
SUMMIT
Backflow Preventers Work Order: 1309913 FIRE P$QTreT,ON
The work covered on this form is performed annually:
Owner: Owner's Phone Number:
Owner's Address:
Property Being Evaluated: ALDI
Property Address: 13747-60TH STREET N,OAK PARK HEIGHTS,MN 55082
Date of Work: 812/17 All responses refer to the current work(inspection,testing and maintenance)performed on this date.
Location of Assembly: Back stockroom Backflow Preventer Serves: Domestic and irrigation
Type of Assembly:0 RPZ 0 DCV 0 PVB Size:1-1/2"
Manufacture: Wilkins Zurn Model: 975XL Serial#: 3391232
Check Valve#2 Check Valve#2
Cheek Valve#1 Relief Valve Test#1 Test#2 Pressure
Back Pressure Confirmation
Vacuum Breaker
0 Leaked 0 Leaked 0 Leaked Opened: 0 Y ❑N
C]Closed Tight Opened: 0 Y 0 N 0 Closed Tight 0 Closed Tight Air inlet opened at:
Differential pressure Differential pressure Differential pressure psi
across check valve: Opened at: 2.0 psi across check valve: across check valve: 0 Leaked
9.9 psi , psi psi _ 0 Held at: psi
❑Cleaned Only 0 Cleaned Only 0 Cleaned Only 0 CIeaned Only 0 Cleaned Only
Replaced: Replaced: Replaced: Replaced: Replaced:
❑Rubber Kit 0 Rubber Kit 0 Rubber Kit 0 Rubber Kit 0 Rubber Kit
1 l CV Assembly 0 CV Assembly 0 CV Assembly 0 CV Assembly 0 CV Assembly
or or or or or
❑Disk 0 Disk 0 Disk 0 Disk 0 Disk
❑0-Rings ❑0-Rings ❑0-Rings ❑0-Rings ❑0-Rings
❑Seat 0 Seat 0 Seat 0 Seat 0 Seat
❑Spring ❑Spring 0 Spring 0 Spring ❑Spring
0 Stem/Guide 0 Stein/Guide 0 Stem/Guide 0 Stem i Guide 0 Stem/Guide
❑Retainer 0 Retainer 0 Retainer 0 Retainer 0 Retainer
❑Lock Nuts 0 Lock Nuts 0 Lock Nuts 0 Lock Nuts 0 Lock Nuts
❑Other: 0 Other: 0 Other: 0 Other. 0 Other:
Differential pressure Differential pressure Differential pressure Air inlet: psi
across check salve: Opened at: psi across check valve: across check valve: Check valve:
psi psi psi psi
Note:All repairs shall be completed within ten(10)days.
Install Date: Rebuild Done:0 Y 0 N Rebuild Date:
Coments
Check#2 FAILS. NEEDS TO BE REBUILT. FAILED LAST Inspector's Information
YEAR ALSO.❑
Inspector Reed Lord Company: Summit Companies
I THINK THIS BACKFLOW IS IN THE WRONG SPOT. I
Company Address: 575 Minnehaha Ave,St.Paul,MN 55103
THINK IT WAS MEANT TO SEPARATE THE IRRIGATION I state that the information on this form is correct at the time and place
FROM THE DOMESTIC. THERE IS NOT ANYTHING DOING
THAT. SERIOUS PROBLEM. of my inspection,and that all equipment tested at this time was left in
operating condition upon completion of this inspection except as noted
in the comment section above.
Signature of Inspector. Date: 8/2117
License or Certification Number(if applicable): BT710638
State License Number - MN:C0075 / IA:FP-036 i WI:656060
Summit Fire Protection 1575 Minnehaha Avenue West-St.Paul,MN 55103 1 Phone(651)251-18801 Page 1 of 1