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HomeMy WebLinkAbout2016 AIE Inspection Services Backflow Prevention Test Reports Please print all AIE Inspection Services, Inc. information neatly I� Backflow Prevention 5?)r5 s'vr( ' Q,_, _,,,,i Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1030 Phone 651-439-7476 Job# 1G563 Cert Exp Date 12-31-2016 Alarm CO.WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Riser Room. Usage:Domestic Mfg Model Size Serial# Type: Reduced Pressure Zone Watts 909 3" 179856 Orientation: Horizontal Protection: Isolation Height off Meter/Acct# Floor 4 (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge'?Yes Installed N/A Double Check Valve Assembly P sessu ck-relief) lief) NDifferenNe/A Date (1 N/A i Rebu lt, CHECK VALVE#1 CHECK VALVE#2 - RELIEF VALVE PVB/ VB ` Held at 0 PSID Held at PSID Opened at PSID AIR INLET Leaked ❑X Closed Tight 0 Did Not Open 0 Opened at PSID Leaked 0 Did Not Open ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned v, ❑ Replaced: ❑ Replaced: El Replaced: ❑ Replaced: CC i.1.1 w2` _ Air Inlet PSID z PSID PSID LL PSID Check Valve PSID Closed Tight © Leaked C] 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: NSA 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 9-16 n Certification Tag Placed on BFP at Completion of Test 0 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 0611-AIE-DIGITAL EDITION 082211 Please print all AIE Inspection Services, Inc. information neatly h Backflow Prevention IS _q: . 1N.) Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights, MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1045 Phone 651-439-7476 Job# 1 G563 Cert Exp Date 12-31-2016 Alarm CO.WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Riser Room. Usage:Fire Type: Double Detector Check-Bypass Ammlie Model Si41# es 2000E 3/4"" 41196 Orientation: Horizontal Protection: Containment Height off Meter/Acct# Floor 4' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date *Relief ports on RPZ free of continuous discharge? Installed N/A Double Check Valve Assembly 1 ck-relief) NSre Difference DateA Rebuilt ( N/A {1 ck- , CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB E Held at 1.0 PSID Held at 1.2 PSID Opened at PSID AIR INLET -- Leaked 0 Closed Tight 0 Did Not Open 0 Opened at PSID Leaked ❑ Did Not Open 0 0 Cleaned ❑ Cleaned El Cleaned 0 Cleaned ,„ ❑ Replaced: El Replaced: 0 Replaced: ❑ Replaced: tr.w' 4 0 LSU 2 t _ Air Inlet PSID Z PSID PSID LL PSID Check Valve PSID Closed Tight Q Leaked LI PASS NI 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 9-16 Q 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 Inspection Services, Inc.AIE information neatly Backflow Prevention (<A. ,IN(ur\ii c i J\i' Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address W Address 6170 NE River Road Inspector Lenny Burgess Date 13-4-16 Oak Park Heights, MN. Sauk Rapids,MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1100 Phone 651-439-7476 Job# 1G563 Cert Exp Date 12-31-2016 Alarm ccVM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Riser Room. Usage:Fire Mfg Model Size Serial# Type: Double Check Ames 3000SS 8" 137787 0205 Orientation: Horizontal Protection: Containment Height off Meted Acct# Floor 4' (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 (1st ck-relief) N/AN/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB a E Held at 0 PSID Held at 2.0 PSID Opened at PSID AIR INLET F- Leaked ❑x Closed Tight x❑ Did Not Open 0 Opened at PSID Leaked ❑ Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned v, 0 Replaced: 0 Replaced: ❑ Replaced: ❑ Replaced: ccw 0 wg et Air Inlet PSID z PSID PSID LL PSID Check Valve PSID Closed Tight ❑X 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 -:_- •-- . empted cleaning,flushing or unclogging of test cocks. Need to replace three 3/4"inch Ball Valve/Tests Valves. Test Kit Make Midwest Model 845 Serial # 10060303 Last Calibration Date 9-16 t^I Certification Tag Placed on BFP at Completion of Test XO 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 DO,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-ME-DIGITAL EDITION 082211 Please print all p information neatly AIE Inspection Services, Inc. Backflow Prevention g' ,ti ` C. q Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1115 Phone 651-439-7476 Job# 1 G563 Cert Exp Date 12-31-2016 Alarm CO.WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located at Back Mop Sink. Usage:Domestic Mfg Model Size Serial# Type: Watts 800M4 3/4" 403973 Orientation: Vertically Up Protection: Isolation Height off Meter)Acct# Floor 8' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date * Relief ports on RPZ free of continuous discharge? Installed 2-16 Double Check Valve Assembly (1 Pressure Difference Date N/A ck-relief) N/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB VB J Q E Held at PSID Held at PSID Opened at PSID AIR INLET Leaked ❑ Closed Tight 0 Did Not Open 0 Opened at 1.6 PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned co ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: oew w2 cc Air Inlet 1.6 PSID -J z PSID PSID LL PSID Check Valve 1.8 El Closed Tight ❑ Leaked u PASS f 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 9-16 0 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)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! 8FP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all RECEIVED information neatly J,) AIE Inspection Services, Inc. Civ. Backflow Prevention ��� Assembly Test Report Inspected By Ci of Oak Park Heights Store# WM-1861 Company Quality Design&Fire -A Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1130 Phone 651-439-7476 Job# 1 G563 Cert Exp Date 12-31-2016 Alarm Co WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Garden Center Valve Room. Usage:Irrigation Type: Reduced Pressure Zone Mfg Model Size Serial# Wilkens 975RP 2" 037127 Orientation: Horizontal Protection: Isolation Height off Meter/Acct# Floor 2' (iNft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A Relief ports on RPZ free of continuous discharge?Yes Installed Double Check Valve Assembly Pressure DifferenceRete {1(1stNck-relief) NIA F�ebuift, N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVBISVB E Held at 7.2 PSID Held at 0 PSID Opened at 3.0 PSID AIR INLET Leaked 0 Closed light 0 Did Not Open 0 Opened at PSID Leaked ❑X Did Not Open 0 0 Cleaned 0 Cleaned 0 Cleaned ❑ Cleaned ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: rt Air Inlet PSID Z PSID PSID ai PSID Check Valve PSID Closed Tight ❑ Leaked fl PASS FAIL NI 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 9-16 ❑X 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 Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all p information neatly AIE Inspection Services, Inc. 5---xi'" Backflow Prevention \' c ✓i' Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights, MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1145 Phone 651-439-7476 Job# 1G563 Cert Exp Date 12-31-2016 Alarm Co.WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Deli. Usage:Domestic Mfg Model Size Serial# Type: Watts 008QT 3/4" 00692 Orientation: Vertically Up 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? Installed Pressure Difference Date Double Check Valve Assembly (1st ck-relief) N/AN/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB VQ� -J a E Held at PSID Held at PSID Opened at PSID AIR INLET LeakedTi ❑ Closed Tight 0 Did Not Open 0 Opened at PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: ww w2 cc Air Inlet PSID a PSID PSID iT_Z PSID Check Valve 0 PSID Closed Tight ❑ Leaked LJ 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 9-16 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)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 0611-AIE-DIGITAL EDITION 082111 Please print all I� information neatly AIE Inspection Services, Inc. Backflow Prevention c,si_s �N(` li Jxl Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights, MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1200 Phone 651-439-7476 Job# 1 G56312-31-2016 Cert Exp Date Alarm Co.WM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Bakery. Usage:Domestic Mfg Model Size Serial# Type: Watts 008QT 3/4" 00936 Orientation: Vertically Up 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? Installed Double Check Valve Assembly Pressure Difference Date (1 ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVIZVI Q E Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked 0 Closed Tight 0 Did Not Open 0 Opened at PSID Leaked 0 Did Not Open 0 El Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned a, ❑ Replaced: El Replaced: 9 Replaced: 9 Replaced: cc Lit 0 w� re Air Inlet PSID z PSID PSID LL. PSID Check Valve 0PSID Closed Tight ElLeaked LI PASS FAIL f No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: NIA 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 9-16 ❑X Certification Tag Placed on BFP at Completion of Test 0 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 tired 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 EDn10N 082211 Please print all Services, Inc.AIE information neatlyInspection 5 1 ?�oy� l .2\IBackflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids,MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1215 Phone 651-439-7476 Job# 1 G56312-31-2016 Cert Exp Date Alarm COWM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Produce Dept. Usage:Domestic Mfg Model Size Serial# Type: Watts 008QT 3/4" 03782 Orientation: Vertically Up 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? Installed PressureN Difference Rete Double Check Valve Assembly N/A {1 ck-relief) N/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB6SV1 1 a E Held at PSID Held at PSID Opened at PSID AIR INLET Leaked 0 Closed Tight 0 Did Not Open 0 Opened at PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned it w ❑ Replaced: ElReplaced: ElReplaced: 1:1 Replaced: 0 a.w� re PSID PSID Air Inlet PSID [I' PSID Check Valve 0 PSID Closed Tight ❑ Leaked CI 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 9-16 ❑X Certification Tag Placed on BFP at Completion of Test El 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 (-- ),� 1\(°'`'JJ _)\) Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address W Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1230 Phone 651-439-7476 Job# 1 G56312-31-2016 Cert Exp Date Alarm COWM Alarm Central Alarm Phone (800)530-9924 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 Double Check Valve Assembly Pressure Difference Date N/A (1 ck-relief) N/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE L VB J Q E Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked 0 Closed Tight 0 Did Not Open 0 Opened at 1.4 PSID Leaked ❑ Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned (0 ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: w w 0 wg w Air Inlet 1.4 PSID z PSID PSID w PSID Check Valve 2.4 PSID Closed Tight 0 Leaked LI 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 9-16 {Ri 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 I� information neatly AIE Inspection Services, Inc. cct s ,'((Aldi), ,r Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 5th St. N.W. Address 6170 NE River Road Inspector Lenny Burgess Date 10-4-16 Oak Park Heights,MN. Sauk Rapids, MN 56379 Certification/ Manager Phone (320)493-8277 License# 090989-BT Time 1245 Phone 651-439-7476 Job# 1 G563 Cert Exp Date 12-31-2016 Alarm COWM Alarm Central Alarm Phone (800)530-9924 Location:Inside Describe location(Please be specific): Located in Meat Dept. Usage:Domestic Mfg Model Size Serial# Type: Watts 008QT 3/4" 08987 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 e Double Check Valve Assembly Preck-relief)ssure DifferenN/ ReA Rebuilt (1N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB1V Q F_ Held at PSID Held at PSID Opened at PSID AIR INLET z Leaked 0 Closed Tight 0 Did Not Open 0 Opened at PSID Leaked ❑ Did Not Open ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned c w 0 Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: 0 wa ft ZciPSID PSID Air Inlet PSID LL PSID Check Valve 0t PSID Closed Tight El Leaked Leaked PASS FAIL f 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 9-16 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)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 0641-AIE-DIGITAL EDmON 082211