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HomeMy WebLinkAbout2019 Interstate Testing RBA Report Aug.25.2019 01:13 PM Interstate Testing 7637555365 #3296 P 12/19 Interstate Testing, LLC PD. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY (RBA)APPLICATION FORM/TEST REPORT COMPLETE JOBADDRESS(INCLUDE Apt/Unit it) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 Norwich Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612)503-7498 O k Park Heights. MN 55062 ,Dear Evenson APPLICANT COMPANY NAME CONTRACTOR LICENSE It CONTACT NAME AND PHONE NUMBER Interstate Testing1LLC PC751575 Donn Miller (763)744-6149 ADDRESS CITY STATE ZIP EMAIL P.O. Box 55 ,Anoka MN 55303 interstatetesting(c comcast.net TESTER NAME TESTER CERI1RCAT)ON p PHONE Donn Miller 187'065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 `��'d.. 'v.�, ��,,ri. .. .. ', �. +�3'�`*,c ��;,�,.ai Vtl�'�i©�+YY�,�!F�'V'.,�,��5�1kQRI1�M��:r�!W►��,��,.i: "A1a •t _ _ _install Relocate. _---._Remove Replace and SNIT of Replaced Device _Rebuild X Test ;,•a. �`�i aCOT,'±�i �. �Sr TQ-ffM" T '�. 4i Ct n4 YX Aa?.SEM■■y LA.. irk B .p'y� 1(1/,�..ri a `'°} °+r i. ` h 1. ,, rt��. � :. Type(check one): .Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection ._._Double Check Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker Spilt Resistant Pressure Vacuum Breaker Manufacturer Wilkins modeitt 975XL serial t► 1327583 size: 1" (inches) System Serviced Pool Fill Location in bldg Pool fill room Floor ti Rooms Pac:Fl.I Pi �►`: a ffil '` (C JM�$. £ 1 1CABL S f�1i 84 f "Yip t�,C1r1 N 8fL.O ) is S, '�° ,.�.' t� rue d PiEesslxre dY nrclpat or Red cad ieksu E ' ct4r;FWPotectaan'1RP .4 `f Cf TS Pressure Differential Check Valee#2 Shutoff Valve s2 Check Valve#1 Relief IffdValve e Initial Closed Tight ,,Yes ,._.No Closed Tight X Yes No Closed Tight L es No Operxd at prld Test Pressure Drop Across Check Valve*19.2 psid Fknal dosed Tight _Yes_No Closed Tight _Yes No Closed Tight es—rao Opened at paid Test Pressure Drop A cross Check Valve# , psid '� '9!:. .l i. ,. 'if , , '. AQUW CheeI;V*4 ar? t#�►!e' eck•tl> c oI iFli► Arott i tlaQ1 DC 1-TEST Vt t'c. h�.1',,<, v Check Valve Al Check Va ve tt2 Shutoff Valve 42 Initial Test dosed Tight `irt psid Closed Tight ^ Yes No paid Closed Tight -�Yes No Final Test Closed light —Yes _No _ psid Closed Tight ,r Yes No psld Closed Tight Yes—No w,,. {; Ar, pr ;s re;;l' iCt m Bref9iift iPVB : �' >lX , sant Ali t iealc�i!''S i/8 ''-T TRE I S >,�;'' ,, ;, ;.a• C. Air Inlet Valve Check Valve Shutoff 42 tnitlal Test . Palled to Open _Yes No Closed Tight Yes No Closed Tight Yes ,T No Opened at,„• ..,,, psid _ Pressure Drop Across Check Valve#1 psld closed Tight Yes No FinalTest Opened at psid Pressure Drop Across Check Valve Closed Tight Yes_ . No IDescribe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be o and that the teste d ce Is functioning in compliance with State of Minnesota Plumbing Code.Chapter4714, TESTER'S SIGNATURE TEST DATE: .U4-19_