HomeMy WebLinkAbout2019 Interstate Testing RBA Report Aug.25.2019 01:10 PM Interstate Testing 7637555365 #3295 P 8/19
interstate Testing, LLC
P0. Box 55
Anoka, MN 55303
REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT
COMPLETE JOB ADDRESS(INCLUDE Apt/Unit ICI NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER
5259 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498
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APPLICANT COMPANY NAME 1 CONTRACTOR LICENSE It CONTACT NAME AND PHONE NUMBER
Interstate Testin. LLC PC751575 •A l ��' 7. 744-1 49
ADDRESS CITY STATE ZIP EMAIL
P.O. Box 55 ,Anoka MN 55303 lnterstatetestinq( corrcast,net
TESTER NAME TESTER CERTIFICATION I PHONE
Donn Miller 6=065323 (763)744-6149
TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL* TEST EQUIPMENTSERIAL S TESTING EQUIPMENT CALi4RATION DATE
Midwest Instruments 845-5 05090906 01-16-18
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Install Relocate Remove —Replace and$N#of Replaced Device -Rebuild X Test
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Type(check one): ,,,,,Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection
_w Double Check Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker
Manufacturer;Watts Model* 009M2 serial 1I 236673 Sire;2" (inches)
System Serviced'Fire System Location in bldg Mech Rm. on Townhouse Flood) Room* Mech
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Check Valve 02 Shutoff Valve 42 Check Valve 41 Pressure Differential
ReliefValve
Initial Closed Tight &Yes ,..._,No Closed Tight Yes_No Closed Tight „ ,,.Yes No Opened at 2.5 psid
Test Pressure Trop Across Check Valve 019.8 psid
Final dosed Tight Yes_No Closed Tight Yes_No Closed Tight _.Yes_,_No
Opened at psid
Test Pressure Drop Across Check Valve 41, psid
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Check Valve Til Check Valve 42 Shutoff Valve 02
Initial Test Closed Tight _._Yes No psid Closed Tight Yes No psid Closed Tight _Yes No
Final Test dosed Tight Yes No old Closed Tight Yes No psid Closed Tight +,Yes No
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Ab Inlet Valve Check Valve Shutoff*2
Initial Test Failed to Open _Yes_No Closed Tight Yes TNo Closed Tight Yes • No
Opened at •,, ,,, psid Pressure Drop Across Check Valve#1 psid
Closed Tleit Yes No
Tonal Test ` Opened at Hasidprero.piss Check Valve tt Closed Tight ®Yes__ No
Describe parts and repairs when needed:
CERTIFICATION: I hereby certify theforegoing information provided by me to be rect and//hat(the test de ce la functioning in compliance with
State of Minnesota Plumbing Code,Chapter 4714. . r . 1
TESTER'S SIGNATURE TEST DATE: 08-24-19_