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Home My WebLink About2019 Interstate Testing RBA Reports Aug.25 2019 01:09 PM Interstate Testing 7637555365 #3296 P 7/19 Interstate Testing, LLC P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY (RBA1 APPLICATION FORM/TEST REPORT COMPLETE KIR ADDRESS 0NCCUOE Apt/Unit it) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5350 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612)503-7498 Part< Heights, MN 55082 Dean Evenson APPLICANT COMPANY NAME CONTRACTOR LICENSE tl CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575 • (763)744-6149 ADDRESS CITY STATE ZIP EMAIL PO. Box 55 Anoka MN ,55303 interstatetesting@comcast.net its,tit NAME TESTER CERTIFTCATtON tt PHONE Donn Miller 137065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL It TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 t:�;or.o,w«•. -.+.• y: ,••r,L v,..:c•.. . � p r. .,y .t ?p' , n f. 'rr ,':,':,a .:-• i,�.� .,�;,;,'ytJ:T.:' lr�s y c 1r�y y. . �ith•:5:';ti'�a ,r„�. 4):,\ ; • „i,••rv'.�1 �'�',a�°,",,,.'fes ,. ]Cv,::•��!'�� ".u'� �t�.,,;. '�•.�� , 7 �?A!1Uti ,� � M� l!<.��1 '± 1l'� . .. r, .,�;,,x,.t,,. .•.Y.•�:,,.;w,��.c...,shiw.� _Install Relocate._Remove Replace and SNft of Replaced Device —Rebuild X Test :.W", •>rVt.r4• :,rj•,W \.. �`il i 1 .:{.. y1r..1.,1. (A7.-4r t ritem;•^(F T',1'�`i(:�i i tw�'?� s),45 C twa�`�+�r� �..:s =. � � ;r.>s �: Type(check one): ,X Reduce Pressure Principal or Pressure Principal Fre Protection Reduced Pressure Detector Fire Protection Double Check Valve _-_Double Check Detector Fire Protection _Pressure Vacuum Breaker Spilt Resistant Pre-.sure Vacuum Breaker Manufacturer:Wilkins Model tl 97X1,- serial# 1690655 size:3/4" _inches) System Serviced Garbage Rinse "'�^ 'i r' kri;',.k;ww• . . rA�_ ,+�.,� Location rc�at�ion...i.n9b ld g Orui�tsidegarbage area. arbagearea.ne a.•.rrceQil>inng f'�,.�o'xo'ErrSg�!" r1itY8R.oo�"rmi s 4-i ` " ' p \ t6i ( 1 *1 (, An �" .., of >�= F 'aTtt�r�� eROd �Qr* �.n� si:.• Mr Check Valve 42 Shutoff Valve#2 Check Valve iti Pressure Differential Relief Vtdve Initial Closed Tight X Yes _No Closed Tight X Yes,No Closed Tight , Yes No Test Pressure.Drop Across Check Valve it 18.8 psi Opened at 4,� psid t Final Closed Tight_Yes_No dosed Tight Yes No Closed Tight _Yes_No Opened at psid Test Pressure Drop Across Check Valve 111 psid _«.......y R.. .�••^^!•...,. •!:•r. :•..-.o•.,. ..V.:, .r.y 1,-.t�;eok��t�c#pr E lPl •rgLtiC��d>rxij `�S.L�#��.�d�'>A;�?•P k:.' '=•?+:,ri,:• Y 1,;ii.Q3 u:'; 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 paid Closed Tight. —Yes—No psid Closed Tight _Yes No .es8iirAVa uu iB'g# iifgof.?Ef*i( l( fii V'Jctlu argkk,OKy0fAfrsl1A $Vgk;.,b,Z A."a Ak inlet Valve Check Valve Shutoff tt2. initial Test Fasted to Open. ,_Yes ,.No Closed Tight Yes wNa _ Closed Tight .....Yes No Opened at _psid Pressure Drop Across Check Valve til psid Cl light Yes No Reel Test Opened at psid Pressure Drop Across Check.Valve#1 Tight .._.Yes No Describe parts and repairs when needed: CERTIFICATION: )hereby certify the foregoing information provided by me to rest and that the de "ce is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714. TESTER'S SiGNATURF TEST DATE: 08-2471a_ Aug.25.2019 01:08 PM Interstate Testing 7637555365 #3296 P 6/19 Interstate Testing, LLC P.O., Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY RBA1 APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit ii) NAME OF BUILDING,OWn1fR/OCCUPANT,CONTACT NAME AND PE NUMBER 5350 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 APPUCANT COMPANY NAME CONTRACTOR LICENSE# CONTACT NAME AM)PHONE NUMBER Interstate Testing, LLC PC751575 _ Dom' Miller (763)744-6149 ADDRESS CITY STATE ZIP EMAIL P.O. Box 55 Anoka MN 55303 interstatetestinq c(l�,comcast.net TESTER NAME TESTER CERTIFICATION 4 PHONE _Donn Miller B=065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 .:_°i. ' ', _v 1 .{ _ ; r of WORKAND;kit-eINFtiRMA.riON'(ch k;o e/4� 4 ` t ,TM*`,. 8 ,.,, 4,, J- _install Relocate _Remove RzIace and SN#of Replaced DeviceRebuild X Test yi ti„f,k p 4..i.'jn�< ::i;ic :s'i Ut ig aA�tiikkitQ !.y,StMBLYD. AI:UNFQ1iMAIIO 1 a, , , .;5 top i , K t4 ..... : Type(check one):2L,Reduce Pressure Principal or Preure Principal Fire Protection Reduced Pressure Detector Fire Protection Double Check Valve Doubk Check Detector Fire Protection _Pressure Vacuum Breaker__,,,Spill Resistant Pressure Vacuum Breaker Manufacturer:WUlkins Model# 975XL serial# 1690660 size:3/4" (inches) System Serviced Boiler Make .. MakeUp Location in hick B.S. Boller Room, bu ilding B FloorsRoom# Boiler 1r� '^7 '• ' IES4,� jc o! ,P. MP .t(0*l0.0;,QMil00 4:4 ST1i'y , . ,��'g.,.'.:' ,::Rr r daii�si •, pwr z ar tAdt 0P 4ure;D e r / : a.s p, W rRts*:.. : - ` 4 t;_ ii Check Valve 42Shutoff Valve#2 Chick Valve#i Pressure DifferentialRelief Valve initial dosed Tight &Yes ,...,,No Ciosed Tight X Yes_No Closed Tight .,,Yes No TestOpened at 3.8 ps[d Pressure Drop Across Check Valve 41 10.6 psid Final dosed Tight ,Yes_No Closed Tight --,Yes No Closed Tight _,_,Yes_No Opened at psid Test Pressure Drop Across Check Valve#1. psid V: , ♦f.b�r4 2 '�_ r . . r r a�i{lipetfit<‘10� ist:1yTCJj} CfGy )ete or❑rae PEOreM'IQflC ') fl3 Ti.. r ,x `.`. a N f. Check Valve#1 Check Valve 42 Shutoff Valve#2 Initial Test posed Tight _.Yes _No psid Closed right Yes No psid Closed Tight Yes No Final Test Closed Tight Yes No psid Closed Tight Yes No psid Closed Tighta Yes No 0T; ; ::; , Pr Ji0.uaicuuri Bireaker-(P )oot' ?ill esistant V uu mm Br'ea&c r(SRVB)—TE.5f"REsUO 4 ,4 , .- . g0 Air Inlet Valve Check Valve Shutoff#2 Initial Test Pailed to Open_Yes_No Closed Tight Yes _No Pressure Drop Across Check Valve#1psid dosed Tight Yes @80 Opened at ,_,.psid _ Frna6 Test Ctosed Tight _Yes _No I Opened at psid Pressure Drop Across Check Valve 41�, psid Closed light _Yes........ No Describe parts and repairs when needed: 1 CERTiF1CATION: thereby certify theforegoing Ir>forrr4ation proorided by me to ec t and that Nie taste device Is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714. ,D`rnI' TESTER'S SIGNATURE,,,,_..,r„�„ . TEST DATE: _24-19 ��