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Home My WebLink About2019 Interstate Testing RBA Reports Aug.25.2019 01:04 PM Interstate Testing 7637555365 #3296 P 2/19 Interstate Testing, LLC P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY(RBA)APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS{INCLUDE Apt/Unit It) NAME OF BURRING,OWNER/OCCUPANtj CONTACT NAME AND PHONE NUMBER 5450 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 ,Oak Pprk Heights, MN 5§Q8? Dean Lein APPLICANT COMPANY NAME CONTRACTOR UCENSE U CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC _ _PC751575 Don.r Miler (763)744-6149 , ADDRESS CITY STATE ZIP EMAIL P.O. Box 55 Anoka MN 55303 interstatetesting@comcast,net i tSitlt NAME TESTER CERTIFICATION It PHONE Donn Miller B:065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL it TEST EQUIPMENT SERIAL U TES11NG EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 .zyr•.i/q},t�„lx:. :;!+A., -'r r,f it.•�. ,n'... 1. hh` �'�`��,(�!„��(•, /� -... r. r'fv.,.:]:'"fir".7'.'x`4 R,y.r. v7;3.M•;.a r�ih Y k gt`",Y ,ti a..f��4 S�F r rr. '5t,7?.. �.A7D FEE lN. eiii0A�!LTLON:, ec Y-v�>,mt vr. I�`ti1^.r.y nil V l4.?7;i, ., _Install_Relocate _Remove ReQtaceand Sy of Replaced Device —Rebuild X_Test i,t „n a• � re ", s$,.�. ,.,y- F t � a�,. i :�•`.ib',,.i+:M1,r, v � ; ` tt; 4 f h �" }�"•'`' }f �y�Wy��. 1t�WYj D�Eean�yy IN }� r 3 .1 i+ T z. v&, 'I p..,.....,_:,6' iit1. �}c___ _ '- __,,._.L..� I� '� '^ 's.. '?; '�, �._'._., :.n'l' ,} a r� Type(check one):,2LReduce Pressure Principal or Pressure Prindpal Fire Protection Reduced Pressure Detector Fire Protection _^Double Check Valve _Double Check Detector Fire Protection _Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manufacturer Wilkins ModeUS 975XL Ser 1690679 site:3/4" _Jinctres) system serviced Chiller Feed Location irnbidg BSA building, Boller Room Floor Room# Roller Rm. ',+: y�: "�r+„aa prr',�i r:N • .�i,i:. � ', 1 n� ,Ay.;yrt,,�� r,�,E, ,µyy .��. .dry �+ �,.. y,., 7�* �,1. r• ..r!�4 473, t? rvg��cL (nEiiiilt ,,�ll#4i. INti COMP) EtAPP'U, r .tir.AS$EMS .E^ E .:, i "'W). .. d, ` : . ° .'Rfi � U* '.X 4 bC {... s4.. .yi�.44ec�oX rt tec i ;4:. .StiO,SULTs r Check Valve 112 Shutoff Valve Ol2 Check Valve Ni Pressure Differential Relief Valve Initial Closed Tight X Yes _No Closed Tight,N,_Yes No Closed Tight ,L Yes No TettPressure.Crop Across Check Valve#19.8 psad Opened at�Q�sld Final closed Tight—Yes.....,_No Closed Tight Yes �No Closed Tight _Yes_Na Opened at___psid Test Pressure Drop Across Check Valve 41_ psid ''' ;'. ; ,S „' 00/i.e eek Va *' oo _ le c..k' or re Protection DC) �*ESULT$';' , iii ... Check Valve#1 I Check Valve 12 Shp toff Valve 442 Initial Test Closed Tight Yes No psid Closed Tight Yes No psid Closed Tight , Yes No Final Test Closed Tight Yes _No psid Closed-Tight Yes No o5i Closed Tight Yes No V;r.'i *d�t i �� 'l i I P 7f�: T, r y�,,,,t '� , ws. s, sti: + f, 4SS'40,. r1ke 01`/:)or ,• ii•s s'ahtNike n<' .. ,�te SR i.' .They'':":N ..is'',..:;‘ ,','• Alr Inlet Valve Check Valve Shutoff 42 Ireitla Test Tailed to Open_Yes,_„No Closed Tight Yes ,___Pio Pressure Drop Across Check Valve Ill psid Closed Tight Yes No at psid Final Test opened at psid Closed sur Drop Across Chick valve it] asid Closed Tight ,.,_,Yes No I Describe parts and repairs when needed: r CERT1F1CATION4 I hereby terttfY the foregoing information provided by me to.1 • rect and that thed ce Is functioning in compliance with State of Minnesota Plumbing Code,Chapter 471.4, i TESTER'S SIGNATURE '^ TESTATE: 0$-24-19 Aug.25.2019 01:06 PM Interstate Testing 7637555365 #3296 P 4/19 interstate Testing, LLC P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit#) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5450 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 APPUCANT COMPANY NAME CONTRACTOR LICENSE It CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575Miller (763)744-6149 ADDRESS CITY STATE 2IP illarl EMAIL PO. Box 55 ,Anoka MN ,55303 linterstatetestingcomcast.net TESTER NAMETESTER CERTIFICATION II PHONE Donn Miller 1 8-065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL TEST EQUIPMENT SERIAL 0 TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 :� �•.. ;.I•- •i,rt +: ,.,1_.. h.4r;r:.� „ren +.1 ra { �,, ` .,'a •ti' 1y 'bC,Y�'•�'.'� :n v'r�,.t"�,.„erstii�r,; :f�'+iitk;•�:M'�7'X, tJ��".;1 "'v^ 1 y , .1;;� "'�L'4 �^`t':iy:; .%� :=.`i�::` �r :.i�t' s�; 3, i,�,,FY.�...;',<,1,J.!o;r��'• 1. �� pi" M: , { Y. k S{ ,t'n r, :�. -' r,�., ti yr, .ih ' 1 uih �Y� �y y�yy r,. 4 S ; y:4 ...�,� ',,l 1a �x ��; ��.�^.".� ?: '� `F;;�`T x,11''', ��rF�A,Rw`.:? .,4'ryl!-r1.fI�1�H��,l!: ,�... � �'?.wS:•�. r.. � ., ��.,, .•hr+,r., t...:i. ;;,L,i 1`, ;�r'!,a.'tR.,ri install`Relocate Remove Replace and SN#of Replaced Device ,Rebuild X Test .3,f.; 'I j;'.M1`7I; Z JS.L'. ,�' r:\1 .1Z 51 ..,. V)•i�,.. ��:,/,:5;,.-Y.•` �':A'1 A� ''L.'”. �.J::^!.. ; :Y • ,` 'b x ;i.•F'•• ,t'-'.' �'S.H Y S,g?+ i'� �.,1 y ;� `..,y,� 1 a ,�` < r &:�; . n:l;i^i<:t�>i t..r t` + d ',�y yy "'r.� �. •7.. w -'i�w�'. !?^',a iy i ....: 1,r.?Zy�� 7. f .� ..`, •1T;�;�. ��..�•<<ri ts.t;.. t' !,L_ Yype(check one): ,ii,„,Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection Double Check Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manufacturer;WiIkins model# 975X1-, serial# W121089 Size,3/4° (inches) System serviced Garbage Rinse Location in bide BSA Building, garbage room prcorft Room# Garbage ..i� ......:1440:00:$01:13:104„ ..F--� ` {+ Q #1, #04- > fl4SY '�S IQ,t B0 r �ay �� . ;1 ` j; 4yy�;,,�jy;,,y`\� ,�y 1 , •-.:z t. '{�",.:.-,,;.:::,..,:,;•,;„,,..„:.q,t { I l !at r f St or. r..R . io ,Orli POi . i , T,'LS" r. L k' r . , r�� .s ��+ �� .i� ��a�i�ssu�e�:t ��alfsf � rit�t� �:a�-��t � Sa , ��,,.� .:.., ,,;. Check Valve It2 Shutoff Valve 02 Check Valve lit Pressure Differential Relief Valve initial Closed Tight 25,...Yes _No Closed Tight X Yes No Closed Tight Yes_No Test Pressure Drop Across Check Valve I31 6.8 psid opened at 4.5 psid Final closed-tight ,___Ye __.No dosed Tight Ycs No Closed Tight , ...Yes..,.,No Opened at psid Test Pressure Drop Across Check Valve 0, psid •.\:'d 9J') .,, •�,.,a.+.a.�r ti"q �r.�.{�r��Y],..y..p.:w.{,.�A..�. A±:n.,� ..[:res (�(y..a�iyQ'��} c f��y�tyyry ''r��y: ,.a' 'y��'.:�:.�.( �[�i.. .-.r.-;..�1-��+ �;2q,:hur,�.::•�'e+:. •.r,.f�� „'!x�y L.kit'ga-5',atf.^r•R'.�4azar1c':6i7• * srck !�tector'. i:ii GrIo itiOi Vitt `,,.4 4.A'v�f[•>:1.> d!d,.,r/, i..o 1 . Check Valve 311 Check Valve ts2 Shutoff Valve 112 Initlei 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 Yes No psid Closed Tight J.- .t.: ! S Y ,p�, n T� yr. y(� ,.t{.yyi,� yea r�ei�..y�tt p c.: p.. �i/ ..r '^ t .r ��S'�r'.".V' .:;4'it'xr. y•'1\11 ' Sr • i PVR,;.•"1.. ; tW,!t,KVacuulii, r04 er: �Y, T ,�.M tS . �s ,+ ..,; Air Inlet Valve Check Valve Shutoff$12 initial Test ; Failed to Open _Yes®No Closed Tight Yes �No Closed Tight Yes No O,. ed at •s;d f Pressure Drop Across Check Valve fa psid Final TestClosed Tight Yes No Opened at psid i Pressure Drop Across Check Valve fel ,ipsid Tight Yes._.. No Describe parts and repairs when needed: ,...D CERTIFICATION: I hereby certify the foregoing information provided by me to b rect and that the tests d ce is functioning in compliance with State of Minnesota Plumbing Coder Chapter 4714. / PM TESTER'S SIGNATURE "^� TEST OATE:.Q 4-19 Aug.25.2019 01:05 PM Interstate Teating 7637555365 #3296 P 3/19 Interstate Testing, LLC P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY ( BA)APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit IO) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT'NAME AND PHONE NUMBER 5450 Nolan Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 oak Park Heigbts, MN 55082 Dean Evenon APPLICANT COMPANY NAME CONTRACTOR LICENSE ft CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575 QQn Miller (763)744-6149 ADDRESS CITY ZIP EMAIL PO. Box 55 Anoka MN 55303 interstatetestinq( comcast.net TESTER NAME TESTER CERTIFICATION It PHONE Donn Miller _B 065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER I TEST EQUIPMENT MODELS TEST EQUIPMENT SERIAL 0 TES1INo EQUIPMENT CAUBRATION DATE Midwest Instruments 1845-5 05090906 01-16-18 +r,`,�, .°l.�. ,�,.y✓^I f,v. >RJ c,�• .�,:.�..,,,�,�„ r _�,:, .r i',v. ''...KY„ ar �i�Yi.Yt'l:u:`_»:'�a:R[C'�:`•l�^'Si�!i•u:i��; f �F.>f i/ ;4;ry i �'y:F;s A `,•s..,.•$=�"T�,a•: q..y:•^:ri%J:'':Z�'.'` �`' M Q . Tmn,� ,.:c�., ,,/' x 6, ac. t �,, „,�,,....;ku.•,:'"�y�x,�,l;z;;,r2;,.xu:�?„�'�..::-:��.,.:' �i:!��WID�K lt1�i7.�1,+� Qil�..,�►C��F,�! ' ,.�I�s�+�a;..�,e... �. •'9; ;;.i . r�. .... ..,r+er�:.�:��.+ . Replace and SN f Replaced Device I Rebuild X Test Install Relocate _Rgmrnre _RSD lE4 P ,.A': •xi .a tn�y, v p;, v.a... ....—.,�. ., ;.� 7•,- . ,.r,A �i�.� N ."f'�'TM:'�;r:. .,,�i,' �:��1�i'<'�:ii..v • +3a :: r-::¢. r , nrr . %�:?r%<.:.r " aC';.ai7�„c ..v'�' <:Ar:,",`.'r. ...t�;"r : S rs}7'n i'fs� ,r y i b �4 . �•c;5,t�',t,s .... t r, Type(check one):,X Reduce Pressure Principal or Pressure Principal Fire Protection — Reduced Pressure Detector Fire Protection Double Check Valve _, Double Check Detector fire Protection _Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manufactwer,WilkirlS Model# 975XL serial# t690666 Size;3/4" (inches) systemserviced Boiler Make Up Location inbidg BSA buildinj, Boiler Room F1oorOr Room ft. Boiler }�r ,W �, iv.�•T3r Jy,'y;; !! �:',.�,a: -,t:e v 'l�.ygrv;," ..,�fit` lag fi ari l fie$ �E'14 : •,'-4'.'2.0), 00,,111•!��•S�I!! 'Aa ,6 '1P ? k t� rr .12 ,.:4 r. c.w .„,5-,:,.,..,>;.. x !�' qs'e, .2) M: ,, ;7` 5' n• ,;-4,:,4,.<;,..,+` ” ;c., ',.0g 4,,;,,it,„,_,.„,i? , dl�t' t i ,esjile.y i r' ,..114E 1a),. , -r'�[ A.,/i4$'I1 -',v-a.• Check vahre n Shutoff Valve Oft Check Valve Pi Pressure Differential Relief Valve initial Closed Tight X Yes _No Closed'right X Yes_.,.No Closed Tight LYes No TestPressure Drop Across Chec kValve f119.0 psId Opened at 3.8 psid Final Closed Tight..,..Yes_No Closed TightYes._No Closed Tight .Yes_No Opened at psid Test Pressure Drop Across Check Valve Ill, psid ..,. .T. ',.t. R .t•Y a 7` y, v-c r l''.-",'`,F; 4 t.,-,:y y ,t•• ii- :So 1 ,.x'F ,• . ,-. ,;' rte,,, :'. `t a.�4 ;`a. 04 �: be k V i e-00',010CeJ�rDetcc fJOi;�,f.Mr. ,r11t�O of f>DC .' ,lF..'; U .7d .},�G rr',i ..>ar sr xn:..r�e Check Valve Ill Check Valve#2 Shutoff Valve#2 initlai Test Closed Tight ,w Yes No psid Closed Tight —Yes No psid Close Tight Yes No Final Test Closed Tight Yes _No paid Closed Tight Yes No psid Closed Tight +Yes No Air Inlet Valve Check Valve 1 Shutoff#2 Nailed to Open _Yes—No Closed Tight _Yes _Mo Closed Tight Yes No (Willa(Tese Opened at____psidI Pressure Drop Across Check Valve 1a Ash/ — Final Test OpenM psid aid {I Closed Tight Yes_ No Pressure DropAcross Check Valve U17 psid `Closed --Yes ,,,, No 1 Describe parts and repairs when needed: CERTIFICATION: thereby certify the foregoing Information provided by me to be t and that the teste de ce Is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714, TESTER'S SIGNATURE f T,, TEST DATE:Q2- 9..