HomeMy WebLinkAbout2019 Interstate Testing RBA Report Aug.25.2019 01:07 PM Interstate Testing 7637555365 #3296 P 5/19
interstate Testing, LLC
P0. Box 55
Anoka, MN 55303
REGULATED BACKFLOW ASSEMBLY (RBA} APPLICATION FORM/TEST REPORT
COMPIE E DDB ADDRESS(INCLUDE Apt/Unit d) NAME OF BUILDING,OwN R/OCCU ANT,CONTACT NAME AND PHONE NUMBER
5260 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498
Oak Park HeiQht5, MN 55082 _Deac) Evenson
APPLICANT COMPANY NAME CONTRACTOR LICENSE# CONTACT NAME AND PHONE NUMBER
Interstate Testing, LLC PC751575 Donn Miller (763)744-6149
ADDRESS CITY STATE ZIP EMAIL
P.O. Box 55 Anoka 1MN 55303 interstatetestingAcomcast.net
TESTER NAME TESTER CERTIFICATION# PHONE
Donn Miller B"--065323 (763)744-6149
TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENTSERIAL# TESTING EQUIPMENT CAUBRATION DATE
Midwest Instruments 845-5 05090906 . 01-16-18
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_Install_Relocate. _._Remove _3eptace and Siad of Replaced Devke __Rebuild X Test
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Type(check one):,X Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector hire Protection
-„�Double Check VaI a _Double Check Detector Fire Protection _._,Pressure Vacuum Breaker Spilt Resistant Pressure Vacuum Breaker
Manufacturer:Wilkins Model U 975XL serial# 1794356 size;3/4° (inches)
syrstemServiced Trash Chute Rinse Location in blot B.S.C. Building, Trash room Floorst Roomlt ""^Rm,
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Check Valve A2 Shutoff Valve#C2 Check Vetere#1Pressure Differential
Relief Valve
Initial Closed Tight X Yes .e.Na Closed Tight X Yes No Closed Tight L.Yes„r Na
Test Opened at 4,0 psid
Pressure Drop Across Check Valve dl 8,6 psid
Final dosed light —Yes_No dosed light Yes_jio Closed Tight _Yes—No Opened at psid
Test Pressure(Drop Across Check Valve Ni psid
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Check Valve#1 Check Valve#2 Shutoff Valve#2
Initial Test dosed Tight Yes No psid Closed Tight Yes ._..No psid Closed Tight Yes No
Final Test Closed Tight —Yes _No psid Closed Tight Yes No psid Closed Tight rYes No
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Alt inlet Valve Check Vatve Shutoff 42
felled to Open_Yes,^,,,,No Closed Tight Yes No
Initial Test — -s- Closed Tight , Yes
Opened at d Pressure Drop Across Check Valve#1 psid
Closed Tight Yes No
Tinel Test ( Opened at prod Pressure Drop Across Check Valve#1 ,psid Closed Tight Yes,,w, No
IDescribe parts and repairs when needed:
CERT!RCATTON; I hereby certify the foregoing information provided by me to be ect and that the testesd cue is functioning in compliance with
State of Minnesota Plumbing Code,Chapter 4714.
PESTER'S SIGNATURE....__ TESr DATE:, ;, 4-19