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HomeMy WebLinkAbout2017 AIE Inspection Services Backflow Prevention Test Reports Please print all information neatly AIE Inspection Services, I nc1 EIVED ',; );r , Backflow Prevention Assembly Test ReportJAN 2 4 2018 Inspected By Store# WM-1861 Company Quality Design & Fire City of Oak Park He.fits Address _3.40 _st.+_W Address 780 Mayhew Lake Rd. NE Inspector Lenny-Bur;$ess—At`t_3 - g ,' - 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT " Time 1715 Phone 651-439-7476 Job# 1 H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central Alarm Phone 497-273-4600 Location: Inside '• I Describe location(Please be specific): Located in Riser Room. Usage:Domestic Mfg Model Size Serial# Type: Reduced Pressure Zone 'V Watts 'V 909 3" 179856 Orientation: Horizontal ' Protection: Isolation .r Height off i Meter;Acct# Floor 4' (in/ft) i N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A * Relief ports on RPZ free of continuous discharge? Yes 'V Installed Double Check Valve Assembl Pressure Di)ferenDate Y Ne(15'ck-relief) _ N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J Q C Held at 0 PSID Held at PSID Opened at PSID AIR INLET — Leaked ❑X Closed Tight El Did Not Open ❑ Opened at PSID Leaked El Did Not Open El ❑ Cleaned ❑ Cleaned ❑ Cleaned C Cleaned ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: cw 0 w < — cc Air Inlet PSID Q PSID PSID 7 W PSID Check Valve PSID Closed Tight ❑X Leaked ❑ PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight I)( Leaked C Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest 'V Model 845 ir Serial # 10060303 'V Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD, Defiance, MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification! Manager Phone (320)493-8277 License it 090989-BT ' Time 1730 Phone 651-439-7476 Job# 1H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central w Alarm Phone 497-273-4600 V Location:Inside V Describe location(Please be specific): Located in Riser Room. Usage:Fire Type: Double Detector Check-Bypass � Mfg Model Size" 1# YP Ames � 2000B 3/4" 41196 Orientation: Horizontal 'V Protection: Containment ir Height off Meter/Acct# Floor 4' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A * Relief ports on RPZ free of continuous discharge? 'V Installed Double Check Valve Assembly Pressure DifferenceDate N (15'ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J d_ Held at 0 PSID Held at PSID Opened at PSID AIR INLET Z Leaked Q Closed Tight ❑ Did Not Open 0 Opened at PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned 0 Cleaned ❑ Cleaned rn ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: cc w 0 w m cc J Air Inlet PSID z PSID PSID LL PSID Check Valve PSID Closed Tight ❑ Leaked ❑ PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest yr Model 845 1r Serial # 10060303 'V Last Calibration Date 9-17 n Certification Tag Placed on BFP at Completion of Test ❑X BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected 8y __ Store WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess Date 11-8-17 Oak Park Heights,MN. St Cloud,MN.56304 Certification/ Manager Phone (320)493_8P77 License#090989-BT Time 1745 Phone 651-439-7476 Job# 1 H565 Cert Exp Date 12-31-2018 Alarm C(1WM Alarm Central w Alarm Phone 497.273-4600 Location:Inside w Describe location(Please be specific):Located in Riser Room. Usage:Fire Type:Double Check Mfg Model Size Serial# Ames 'V 3000SS 8" 137787 0205 Orientation:Horizontal ♦ Protection:Containment v. Floor REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A *Relief ports on RPZ free of continuous discharge? 'V Installed Pressure Difference Date Double Check Valve Assembly (1"ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVBISVB J Q E' Held at 0 PSID Held at 2.0 PSID Opened at PSID AIR INLET E Leaked ❑X Closed Tight ® Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned ❑ Cleaned 0 Cleaned ❑ Cleaned m ❑ Replaced: ❑ Replaced: ❑ Replaced: 0 Replaced: tr w w2 Air Inlet PSID PSID PSID -,7- I�I PSID Check Valve PSID LL Closed Tight Inf Leaked fl PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight e Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note:Include hose stream demand where applicable Please note it attempted cleaning,gushing or unclogging of test cocks. Test Kit Make Midwest 'V Model 845 Serial# 10060303 'V Last Calibration Date 9-17 ri Certification Tag Placed on BFP at Completion of Test © BFP in Service Inspector's Signature Customer Signature Print Name&Title 1314 Hwy DD,Defiance,MO 63341 (636)398-5288 Fax:(636)8284634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0811-AIE-DIGITAL EDITION 082211 Please print neat) AIE Inspection Services , Inc. informationy Backflow Prevention Assembly Test Report Inspected By Store # WM-1861 Company Quality Design & Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 11-8-17 Oak Park Heights. MN. St Cloud, MN. 56304 Certifications Manager Phone (320) 493-8277 License tt 090989-BT v Time 1800 Phone 651-439-7476 Job # 1H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central w Alarm Phone 497-273-4600 lir Location: Inside lor Describe location (Please be specific): Located at Back Mop Sink. Usage: Domestic V Mfg Model Size Serial # Type: 'V Watts ' 800M4 3/4" 403973 Orientation: Vertically Up ' Protection: Isolation mr Height off Meter!Acct # Floor 8' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge? NrInstalled 2-16 Double Check Valve Assembl Pressure Difference Date Y (1st ck-relief) N/A Rebuilt N/A J CHECK VALVE #1 CHECK VALVE #2 RELIEF VALVE PSVB Q 1 Held at PSID Held at PSID Opened at PSID AIR INLET — Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at 2.2 PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned Cn ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: LY LE Q 0 — --- Q w 2 — — — -- ----- ---------- c Air Inlet 21 PSID zPSID PSID ------ --_ I PSID Check Valve 2.0 PSID Closed Tight ❑ Leaked ❑ PASS I FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked `— Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning, flushing or unclogging of test cocks. Test Kit Make Midwest ' Model 845 Serial # 10060303 Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test X BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD, Defiance, MO 63341/ Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611 -AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess I' Date 11-8-17 Oak Park Heights,MN. St Cloud,MN.56304 Certification/ Manager Phone (320)493-8277 Licensed 090989-BT Time 1815 Phone 651-439-7476 Job# 1H565 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central., Alamt Phone 497-273-4600 Location:Inside Describe location(Please be specific):Located in Garden Center Valve Room. Usage:Irrigation V T Reduced Pressure Zone Mfg Model Size Serial# Type: Wilkens `v 975RP 2" 037127 Orientation:Horizontal Ay Protection: Isolation Height o6 Meter/Acct# Floor 2' (in/6) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A *Relief ports on RPZ free of continuous discharge?Yes v' Installed Double Check Valve AssemblyPressure Difference Date N/A (1 ck-relief) N/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB a' Q E Held at 6.8 PSID Held at 0 PSID Opened at 3.0 PSID AIR INLET z Leaked 0 Closed Tight 0 Did Not Open 0 Opened at PSID Leaked ® Did Not Open 0 ❑ Cleaned 0 Cleaned ❑ Cleaned 0 Cleaned u, ❑ Replaced: 0 Replaced: ❑ Replaced: 0 Replaced: rew ap w2 w Air Inlet PSID PSID PSID Z PSID Check Valve PSID a Closed Tight 11 Leaked fl PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight Xe Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note:Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest Model 845 Serial# 10060303 Last Calibration Date 9-17 7 Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name&Title 1314 Hwy DD,Defiance,MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store # VVM-1861 Company Quality Design & Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320) 493-8277 License # 090989-BT 'V Time 1830 Phone 651-439-7476 Job # 1H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central v- Alarm Phone 497-273-4600 lir Location: Inside V Describe location (Please be specific): Located in Deli. Usage: Domestic v Mfg Model Size Serial # Type: 1r Watts IF 008QT 3/4" 00692 Orientation: Vertically Up V Protection: Isolation lor Height off Meter/ Acct # Floor 5' On/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge? Installed N/A Double Check Valve Assembl Pressure Difference Date y (1st ck-relief) N/A Rebuilt N/A CHECK VALVE #1 CHECK VALVE #2 RELIEF VALVE PVE/SVB J Q �- Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked ❑ Closed Tight D Did Not Open ❑ Opened at_ PSID Leaked 0 Did Not Open ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned U, n Replaced: ❑ Replaced: (1 Replaced: ❑ Replaced: ccw w < Needs replacement c Air Inlet PSID Q PSID PSID z PSID Check Valve 0 PSID Closed Tight ❑ Leaked ❑ PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight Leaked 111 Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning, flushing or unclogging of test cocks. "Needs replacement Test Kit Make Midwest l• Model 845 V Serial # 10060303 1r Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test X BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD, Defiance, MO 63341/ Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611 -AIE -DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire I Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification! Manager Phone (320)493-8277 License# 090989-BT 'V Time 1845 Phone 651-439-7476 Job# 1H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central w Alarm Phone 497-273-4600 1r Location: Inside Describe location(Please be specific): Located in Bakery. Usage: Domestic Mfg Model Size Serial# Type: V' Watts 'V 008QT 3/4" 00936 Orientation: Vertically Up 'V Protection: Isolation Height off Meter!Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge? v• Installed N/A Double Check Valve Assembly Pressure Difference(1st Ne (15S ck-relief)_ !A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB) J Q C Held at PSID Held at PSID Opened at PSID AIR INLET Z Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned co ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: o' w wo - < Needs replacement Air Inlet PSID Q PSID PSID z PSID Check Valve 0 PSID L Closed Tight Q Leaked 11 PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: N/A_—GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks _ Needs replacement Test Kit Make Midwest ' Model 845 Serial # 10060303 'V Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test X BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Pleaseprintall information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess w Date 11-8-17 Oak Park Heights,MN. St Cloud,MN.56304 Certification/ Manager Phone (320)493-8277 License p 090989-BT 'V Time 1900 Phone 651-439-7476 Job# 1H565 Cert Exp Date 12-31-2018 Alarm C0.WM Alarm Central-‘, Alarm Phone 497-273-4600 Location:inside Describe location(Please be specific):Located in Produce Dept. Usage:Domestic Mfg Model Size Serial# TYPe: ' Watts I_008QT 3/4" 03782 Orientation:Vertically Up w Protection: Isolation Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A Relief ports on RPZ free of continuous discharge? V Installed Double Check Valve Assembl Pressure DifferenceDate y (1s`ck-relief) N//A Rebuilt _,, N�/A,, CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB1;'vty a E Held at PSID Held at PSID Opened at PSID AIR INLET K Leaked ❑ Closed Tight ❑ Did Not Open 0 Opened at _ PSID Leaked ❑ Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned 1n ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: Kw w0 Leeds replacement ce • Air Inlet_- PSID i PSID PSID LL r-� PSID Check Valve 0 PSID Closed Tight I I Leaked n PASS FAIL I No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Needs replacement l Test Kit Make Midwest v- Model / 845 Serial# 10060303 Last Calibration Date 9-17 n Certification Tag Placed on BFP at Completion of Test Q BFP in Service Inspector's Signature Customer Signature Print Name&Title 1314 Hwy DD,Defiance,MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Repots Rev 0011-Am-DIGITAL EDITION 082211 Please print all/ AIE Inspection Services, Inc. Information neatly Backflow Prevention Assembly Test Report Inspected By Store # WM-1861 Company Quality Design & Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess • Date 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320) 493-8277 License # 090989-BT • Time 1915 Phone 651-439-7476 Job # 1 H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central • Alarm Phone 497-273-4600 • Location: Inside • Describe location (Please be specific): Located in Produce at Culligan Unit. Usage: Domestic • Mfg Model Size Serial # Type: • Watts • 800M4 3/4" 64606 Orientation: Vertically Up • Protection: Isolation Height off Meter) Acct # Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge? • Installed N/A Pressure Difference Date Double Check Valve Assembly (1stck-relief) N/A Rebuilt _ N/A CHECK VALVE #1 CHECK VALVE #2 RELIEF VALVE PVB/SVB J Q E- Held at PSID Held at PSID Opened at PSID AIR INLET Z Leaked D Closed Tight ❑ Did Not Open ❑ Opened at 0 PSID Leaked ❑ Did Not Open ❑X ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Replaced: n Replaced: ❑ Replaced: n Replaced: ixw Q o Q w 2 — -- -- — --------- -- — IY Air Inlet 0 PSID Q PSID PSID ZEl PSID Check Valve PSID Closed Tight C Leaked El PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning, flushing or unclogging of test cocks. Test Kit Make Midwest • Model 845 • Serial # 10060303 • Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test X BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD, Defiance; MO 63341/ Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611 -AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design& Fire Address 3400 5th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess IF Date 11-8-17 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT ' Time 1945 Phone 651-439-7476 Job# 1 H565 Cert Exp Date 12-31-2018 Alarm Co. WM Alarm Central ' Alarm Phone 497-273-4600 Location: Inside yr Describe location(Please be specific): Located in Meat Dept. Usage: Domestic Nor Mfg Model Size Serial# Type: ' Watts IF 008QT 3/4" 08987 Orientation: VerticallyUp ' Protection: Isolation Height off Meter!Acct# Floor 5' _ _(Int) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A * Relief ports on RPZ free of continuous discharge? ' Installed Double Check Valve Assembl Pressure DifferenceDate y N/(1st ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J Q C Held at PSID Held at PSID Opened at PSID AIR INLET Z Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned cn ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: ww w <_ Needs replacement Air Inlet___ PSID z PSID PSID PSID Check Valve 0 ❑PSID Closed Tight ❑ Leaked PASS FAIL ✓ No.2 Shutoff Valve Supply Pressure 50 Closed Tight Ei Leaked Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Needs replacement Test Kit Make Midwest Nor Model 845 Serial # 10060303 lir Last Calibration Date 9-17 X Certification Tag Placed on BFP at Completion of Test 171 BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636) 398-5288 Fax:(636) 828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD, Defiance. MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211