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HomeMy WebLinkAbout2018-9-19 AIE Inspection Services Backflow Prevention Test Reports Pleaseprintall p 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 9-19-18 Oak Park Heights,MN. St Cloud,MN.56304 Certification/ Manager Phone (320)493-8277 License#090989-BT ' Time 1215 Phone 651-439-7476 Job# 1J563 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 Riser Room. Usage:Domestic Mfg Model Size Serial# Type:Reduced Pressure Zone ' Watts V' 909 3" 179856 Orientation:Horizontal IF Protection: Isolation FlooroffMeter/Acct# Floor 4' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A *Relief ports on RPZ free of continuous discharge?Yes 1r Installed Double Check Valve Assembly Pressure Difference Rete (1"ck-relief) N/A Rebuilt 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J E Held at 7.2 PSID Held at 2.4 PSID Opened at 2.4 PSID AIR INLET Leaked 0 Closed Tight ❑X Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned rn ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: CC w 0 uJ Z PSID PSID i2 Air Inlet PSID z PSID Check Valve PSID Closed Tight 0 Leaked PASS ✓ FAIL No.2ShutoffValve 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 if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest 'V Model 845 yr Serial# 10060303 'V Last Calibration Date 7-19 © Certification Tag Placed on BFP at Completion of Test IXI 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 RECEWED Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention h` 2 7 Assembly Test Report City of Oak Park Heights1 Inspected By 1......5 Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess V Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT '' Time 1230 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central Alarm Phone 497-273-4600 V Location: Inside Describe location(Please be specific): Located in Riser Room. Usage:Fire N. Mfg Model Size Serial# Type: Double Detector Check-Bypass 'V Ames V 2000B 3/4" 41196 Orientation: Horizontal IF Protection: Containment Height off Meter/Acct# Floor 4' (ice) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A * Relief ports on RPZ free of continuous discharge? V Installed Pressure Difference Date Double Check Valve Assembly (1st ck-relief) N/A Rebuilt 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB E Held at 2.4 PSID Held at 2.4 PSID Opened at PSID AIR INLET g Leaked 0 Closed Tight ❑X Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open D El Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned cn ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: Ce LU 0 w2 ce Air Inlet PSID z PSID PSID Z PSID Check Valve PSID __ Closed Tight El Leaked a PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight El 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 1r Model 845 V Serial # 10060303 'V Last Calibration Date 7-19 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 • n information neatly AIE Inspection Services , Inc. 1 Backflow Prevention 1N I` 2 7 Assembly Report Re o rt l Inspected By 1 City of Oak Park Heights Store # WM-1861 Company Quality Design & Fire =P �;`�' �" ` } � Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320) 493-8277 License # 090989-BT 1r Time 1245 Phone 651-439-7476 Job # 1J563 Cert Exp Date12-31-2018 Alarm Co.WM Alarm Central r Alarm Phone 497-273-4600 V Location: Inside lir Describe location (Please be specific): Located in Riser Room. Usage: Fire lir Mfg Model Size Serial # Type: Double Check ' Ames lir 3000SS 8" 137787 0205 Orientation: Horizontal lir Protection: Containment 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? _ Installed Double Check Valve Assembl Pressure Difference Date y (1st ck-relief) N/A Rebuilt 4-18 CHECK VALVE #1 CHECK VALVE #2 RELIEF VALVE PVB/SVB _- H Held at 3.4 PSID Held at 3.6 PSID Opened atPSID AIR INLET _ z Leaked ClClosed Tight 0Did Not Open ❑ Opened at PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned LI Cleaned u) ❑ Replaced: n Replaced: ❑ Replaced: ❑ Replaced: ccw 74 Q w -- c J Air Inlet PSID z PSID PSID PSID Check Valve PSID Closed Tight ❑X Leaked ❑ PASS I FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight 13 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 1r Model 845 V Serial # 10060303 ' Last Calibration Date 7-19 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 i------ RECEIVED Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention N, 2 7 ,:,....i.;:7': Assembly Test Report C,«yr.fn�t,P.?rk1--!e,atits 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 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT ' Time 1330 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central '• Alarm Phone 497-273-4600 Location: Inside Describe location(Please be specific): Located at Front Mop Sink, GM Entry. Usage: Domestic lir Mfg Model Size Serial# Type: ' Watts II 800M4 3/4" 405492 Orientation: Vertically Up ' Protection: Isolation Height off Meter/Acct# Floor__. 8' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 2-16 Relief ports on RPZ free of continuous discharge? ' Installed Pressure Difference Date Double Check Valve Assembly (1st ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVBISVB J Q t=' Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked D Closed Tight 0 Did Not Open 0 Opened at 2.6 PSID Leaked 0 Did Not Open 0 ❑ Cleaned E Cleaned E Cleaned El Cleaned r„ n Replaced: ❑ Replaced: n Replaced: n Replaced: ccw 0 w w Air Inlet 2.6 PSID z PSID PSID " ❑ PSID Check Valve 3.2 PSID Closed Tight Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight LJ 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 I Model 845 Serial # 10060303 l Last Calibration Date 7-19 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 DO, Defiance, MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all RECEIVED information neatly AIE Inspection Services, Inc. Backflow Prevention 1 Ni.:,'..' 2 7 ::418 Assembly Test Report Inspected By Store# WM-1861 Company Quality Design & Fire .w Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT ' Time 1300 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central r Alarm Phone 497-273-4600 Location: Inside Iri Describe location(Please be specific): Located at Back Mop Sink. Usage: Domestic N. Mfg Model Size Serial# Type. ler Watts 'V 800M4 3/4" 403973 Orientation: Vertically Up 'V Protection: Isolation Height off Meter/Acct# Floor 8' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 2-16 * Relief ports on RPZ free of continuous discharge? ' Installed Double Check Valve Assembl Pressure DifferenDate yNe(1st ck-relief) !A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J a Held at PSID Held at PSID Opened at __ PSID AIR INLET z Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at 4.0 PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned w ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: rtw 0 CL w � W J Air Inlet 4.0 PSID z PSID PSID LL PSID Check Valve 2.2 PSID Closed Tight ❑ Leaked El PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight H 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 lir Model 845 lri Serial # 10060303 ' Last Calibration Date 7-19 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 AIE Inspection Services, Inc. 1. information neatly RECLG ED Backflow Prevention N. 2 Assembly Test Report I Inspected By I City ei 'c Heights Store# WM 1861 Company Quality Design &Fire II Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess 'V Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1315 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm CO WM Alarm Central IF Alarm Phone 497-273-4600 Nr Location: Inside Nor Describe location(Please be specific): Located in Garden Center Valve Room. Usage: Irrigation lir Mfg Model Size Serial# Type: Reduced Pressure Zone 'V Wilkens 'V 975RP 2" 037127 Orientation: Horizontal 'V Protection: Isolation Height off Meter(Acct# Floor 2' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A * Relief ports on RPZ free of continuous discharge? Yes IF Installed Double Check Valve Assembl Pressure Difference Date y (1st ck-relief) N/A Rebuilt 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB Q Held at 8.6 PSID Held at 1.6 PSID Opened at 4.2 PSID AIR INLET z Leaked ❑ Closed Tight ❑X Did Not Open 0 Opened at PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Replaced: n Replaced: ❑ Replaced: C Replaced: Or til 0 tu cc Air Inlet PSID z PSID PSID ZPSID Check Valve PSID Closed Tight C1 Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight M 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 'V Model 845 lir Serial # 10060303 'V Last Calibration Date 7-19 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 3 Assembly Test Report I Inspected By I Store# WM-1861 Company Quality Design &Fire 4 Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT ' Time 1345 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central v Alarm Phone 497-273-4600 v Location: inside 1r Describe location(Please be specific): Located in Deli. Usage: Domestic 1r Mfg Model Size Serial# Type: ' Watts II 800M4 3/4" 044320 Orientation: Vertically Up ♦ Protection: Isolation NI, Height off Meter/Acct# Floor_5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 4 18 r; * Relief ports on RPZ free of continuous discharge? lir. Installed Double Check Valve Assembl Pressure Difference Date y (let ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVBISVB _J _Q 17' Held at PSID Held at PSID Opened at _ PSID AIR INLET z Leaked ❑ Closed Tight 0 Did Not Open ❑ Opened at 2.2 PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned L Cleaned E Cleaned w ❑ Replaced: n Replaced: ❑ Replaced: ❑ Replaced: a w 0 w � J Air Inlet 2.2 PSID z PSID PSID Z PSID Check Valve 3.4 PSID Closed Tight ❑ Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight Fl 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 N. Serial # 10060303 'V Last Calibration Date 7-19 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 , RECEIVED information neatly AIE Inspection Services, Inc. 1 Backflow Prevention 1 2 7 .. Assembly Test Report Inspected By Store# WM 1861 Company C'f of Oa' ori N�',,.- Quality Design &Fire L. Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess I Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 'V Time 1400 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12_31_2018 T Alarm Co.WM Alarm Central Alarm Phone 497-273-4600 Location: Inside lir Describe location(Please be specific): Located in Bakery. Usage: Domestic lir Mfg Model Size Serial# Type: 'V Watts 'V 800M4 3/4" 044348 Orientation: Vertically Up N. Protection Isolation mr Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 4-18 * Relief ports on RPZ free of continuous discharge? l Installed Double Check Valve Assembl Pressure Difference Date y (1St ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVBISVB J Q F"' Held at _PSID Held at _PSID Opened at PSID AIR INLET -, Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at 3.0 PSID Leaked 0 Did Not Open ❑ ❑ Cleaned E Cleaned ❑ Cleaned ❑ Cleaned U, ❑ Replaced: C Replaced: ❑ Replaced: C Replaced: w 0 Q w cc J Air Inlet 3.0 PSID z PSID PSID LL PSID Check Valve 3.6 PSID Closed Tight C Leaked ❑ PASS I FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight ElLeaked 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 Serial # 10060303 'V Last Calibration Date 7-19 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 _ a5..•.CENEO ' t Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention I v. 2 7 Assembly Test Report 1 Inspected By 1 City of Oak.Par'' Store# WM-1861 Company Quality Design &Fire 1 - Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess 'V Date 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 'V Time 1415 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central 'V Alarm Phone 497-273-4600 IF Location: Inside lir Describe location(Please be specific): Located in Produce Dept. Usage: Domestic Mfg Model Size Serial# Type: 'V Watts 'V 800M4 3/4" 044435 Orientation: Vertically Up 1r Protection: Isolation lir Height off Meter/Acct# Floor 5' Jin/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 18 Relief ports on RPZ free of continuous discharge? 1r Installed Double Check Valve Assembly Pressure fffereN/A Date (1St ck-relief) Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB a Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked ❑ Closed Tight 0 Did Not Open ❑ Opened at 3.4 PSID Leaked 0 Did Not Open 0 ❑ Cleaned E Cleaned ❑ Cleaned n Cleaned cn 111Replaced: n Replaced: ❑ Replaced: C Replaced: eCw Tt 0 LI Air Inlet 3.4 PSID z PSID — PSID LT_ PSID Check Valve 3.2 PSID Closed Tight 0 Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight M 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 "V Model 845 Serial # 10060303 l Last Calibration Date 7-19 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! 8FP Report Rev 0611-AIE-DIGITAL EDITION 082211 RE-CriVIT—D —1 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention t" Assembly Test Report City f'Report ; City of 0774k Park Heights 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 9-19-18 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT vr Time 1430 Phone 651-439-7476 Job# 1J563 Cert Exp Date 12-31-2018 Alarm Co.WM Alarm Central ' Alarm Phone 497-2734600 Location: Inside Ar Describe location(Please be specific): Located in Produce at Culligan Unit. Usage: Domestic lir Mfg Model Size Serial# Type: ' Watts ' 800M4 3/4" 044351 Orientation: Vertically Up ' Protection: Isolation Height off Meter/Acct# Floor 5' _ (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date C * Relief ports on RPZ free of continuous discharge? Installed Pressure Difference Date Double Check Valve Assembly (1st ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB J Q �'- 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 1n ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: CC w Q w a Air inlet 2.2 PSID —J z PSID -- PSID L_ PSID Check Valve 1.4 PSID Closed Tight ❑ Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight n Leaked �uuuy 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 'qv Last Calibration Date 7-19 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 RECEIVED Please print all information neatly AIE Inspection Services, Inc Backflow Prevention N 2 i - Assembly Test Report Inspected By City of Oak Park Heights Store# WM-1861 Company Quality Design&Fire . --.:"--- Address _—Address 3400 5th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess ' Date 9-19-18 Oak Park Heights,MN. .,St Cloud,MN,56304 Certification/ Manager Phone (320)493-8277 License#090989-BT 'V Time 1445 Phone 651-439-7476 Job# 1J563 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 Meat Dept. Usage:Domestic lir Mfg Model Size Serial# Type: 'w Febco IF 765 3/4" 976559 Orientation:Vertically Up ♦ Protection'. Isolation 'V Floor 5' (in/ft) N/A Height off Meter/Acct# REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 18 *Relief ports on RPZ free of continuous discharge? 'V Installed Double Check Valve Assembly Pressure DifferenceDate (1s'ck-relief) NN/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE CPVOVB a E Held at PSID Held at PSID Opened at PSID AIR INLET K Leaked 0 Closed Tight 0 Did Not Open 0 Opened at 3.2 PSID Leaked rl Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned „, ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: CL U.1 0 w§ CL Air Inlet 3.2 PSID z PSID PSID LL PSID Check Valve 2.8 PSID Closed Tight ❑ Leaked ❑ PASS I FAIL No.2 Shutoff Valve Supply Pressure 55 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 'V Model 845 V Serial# 10060303 1r Last Calibration Date 7-19 n Certification Tag Placed on BFP at Completion of Test IX1 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