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Home My WebLink About2019 Interstate Testing RBA Reports Aug.25.2019 01:10 PM Interstate Testing 7637555365 #3296 P 9/19 3Gcl0 interstate Testing, LLC nci.rw kP PO, Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY LRBAJ APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit 4) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 Norwich Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 Oak Park Heiahts, MN 550.82 Dem Evensop APPLICANT COMPANY NAME CONTRACTOR LICENSE 4 CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575 QoB,q ill@r (768)744-6149 ADDRESS CITY STATE ZIP EMAIL P.O. Box 55 ,Anoka MN 55303 interstatetesting@comcast,net TESTER NAME TESTER CERTIFICATION a PHONE Donn Miller B=965323 (7Q1)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL 4 'TEST EQUIPMENT SERIAL 0 TESTING EQUIPMENT CAL.iBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 s...:,4a.Y `:r,;;�.tr 5,p ,�':1`A.`x..5ir't.'.l�y/� M .�ts.. } r�.. c!�� N,, ,. Y+,.�••� iy.. K,. (cy nY•�ya, uCe• .. .l�, .�.,.;::: t'`��`J.'ry •a ^..�!'..,,="% " ::.,'�. .t31 gr:l' '_ jvp / y.oit;� tty ►o rk ,1<i�'t�:,f,.ry ,tex.�. iB. L"r :�`sS�s�s x{�Fb�'K •! "• t. m•� .4 rl' n �. ,i 4"! �:" fR *,^,.. 1, „-:ei?5 ; ), R }V thy.y�� i y:. .,., s, 1 ...,., ..,..,:,51,7,,,,,:f• l. _ <v ,. '.(. .�•^ l.,✓:�7:'�l, 'r ,^7'. �- �y. �"?'!ll;"^.1•.i .H's;`�!sf.z 'i1 :.i�f,•e_•N1...i _install Relocate Remove „_.Replace and 5N4 of Replaced Devict Rebuild X Test ;, vr:41 �f1TbP 'r "wiii� K4 *. * 00.•�' �.:a :ni: 0.:%.w;»h2Yy ` k Type(check one): ,Yj,-Reduce 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 modal, 975XLserIeI# 1293783 she`3/4" (inches) System Serviced Boiler Make Up Location in`isidg I.L. Boiler roomy. )} Poor Room# Boller ` y�} S'Zi iirr�Y t 4 .P's .� :3 G 0 0.01 � , Tom„ ,�UF.i*00,,064*1p �'�^�itIrkt ...r ; �,` t 1s,�$;�f � 1r 't. +r► - r 'r •s, t r r. ,4t, ( ,,�r ' a .A�7 " f ��. _ ".' `f k , �e Pyr ip41,. . 4 :Pr 0.t l.Ret fi*f.Pr. t t1 41 4 `. I. . :,1 .• : ;v . Check Valve#2 Shutoff Valve#2 Check Valve 41 Pressure Differential Relief Valve Initial Closed Tight LYes _No dosed Tight,�Yes No Closed Tight ..,Yes w No. Test Opened at 8.8 psid Pressure Drop Across Check 0.2 osld Final dosed Tight —Yes_No dosed Tight Yes_No Closed Tight —Yes—No Opened at paid Test Pressure Drop Across Check Valve*1 psid 2.R..�,,c„ �.r,,lc}yl�a,r ..5�.1�.,�.'�... .,t.�,_r .,far 1w. .71�{�{t /•��. -.P ' t(`�p_r � r,t';`:'Y'.�<�y.(,��,}{`�1tn../�]��j 1»nw�}'j�iiy��i j.J� �j( `;S.s �.'!..a:.��}cYa��i < .l�fi .,Y l ' :gl('�k�',lala`t."L'tri: 4'.��„t'�rtre.44: '; 4k.' p ilii: 1 S4 iii.. • i iiif V4i nciii tit, .l R E ) i')�4�•b. a .. A : .•,fit,. Check Valve 4.1 Check Valve 42 Shutoff Valve 312 Initial Test Closed T ht Yes Na :id Closed Tight Yes No id Closed Tight Yes No t8 ..... Pg .._ _.. ps ..._ ._.. Final Test Closed light Yes No psid Closed Tight Yes No Pa Closed Tight Yes No 45 . +mph:, : 4 ";Br oke+/ ,,:sit s ilr'Ri.Si. tiif►'t V aka .,•ov ' ' T W,i l,""... Air inlet Valve l Check Valve Shutoff 112 F Initial Testi — �_ filed to Open _Yes,_No Closed Tight Yes Na Closed Tight Yes No Opened at,.._�..,,Josid Pressure Drop Across Check Valve MA psid No Final Test Opened at psid Yes Ttgttt _Yes _he Closed Tight _Yes_ No I Pressure Drop Across Check valve 1t1 acid Describe parts and repairs when needed: CERTIFICATION: 'hereby certify the foregoing Information provided by me to b' •'reel and that the t ce is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714. f/ v its/tR'SSIGNATURE ,, �„ TESTDATE:Q 19 . Aug.25.2019 01:11 PM Interstate Teating 7637555365 #3296 P 10/19 5 590 Interstate Testing, LLC n ,,,,,L ' Pi( P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit ig NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 Norwich Parkway Presbyterian Homes (8outwell Landing) Dean Evenson (612) 503-7498 Q_akParkHeiahts. MN 55082 _ Dean Even or) APPLICANT COMPANY NAME CONTRACTOR LICENSE C CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751576 Donr Miller (763)744-6149 ADDRESS CITY STATE ZIP EMAIL RO. Box 55 ,Anoka _MN 55303 interstatetestingcomcast.net TESTER NAME TESTER CERTIFICATION# PHONE Donn Miller B 065326 (7631744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL St TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 Ur.?I'i,, !- ', V/,y.' 4...t•e'i :.{,. 4..vy;. .. \ ,"!' 81 O RK.ANi!;FfE INFORMATION, ctieck:4ir ,:i4 ,n .µ 4. S,+ k. Install Relocate Remove j, R•gylace and SNA of Re•laced y�Device /� Rebuild X Test 1q't'{ b,1 Y!A flys.JA,F u i�}; r �- \,et. �,r •B LO � E N,40;0ETAiL:IN ' ION t�t r� s it tr i Rr ,#,. e g i4,, e' � t4+ !.�,f ;t.�:.5.� ..'YliN•L>-, .L.h�i._ .r�5�h , �� ,. "1Pe �. 7�,. ��"'^�`.., '!.c�k,e Ut..�,2.t.3`i�s.r.. . r ,e�v >>,�:., Type(Check one): .. Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection Double Check Valve ,,.,.,,.,Doable Check Detector Fire Protection ,Pressure Vacuum Breaker Spilt Resistant Pressure Vacuum Breaker Manufacturer:Wilkins Model 975XL Serial# 1298714 Size.,3/4" (inches) System Serviced Location ink{{bldg O..L..�Trash �Rm,,� {�c Floor a �f r 'w'{Room* ^'°"a�, �!'�i�,:'} {. . j,:1 i�" 0. ULTiSM;ami Plass •. ii"f ,t�Z.( PL ETE A "Kt 4k . S EM V TYPE SECT ;404W :�,,, ? '�� 5� a >? .o �':Ri-duce4Pressu ind�or Re`'du± ed Pressure Detecto1 r 'Protec.tl O *i T(ST, :; SULTS ., r. R lZ Check Valve 9t2 Shutoff Valve 02 Check Valve it Pressure Differential Relief Valve Initial Closed Tight X Yes __.No Closed Tight X Yes No Closed Tight XYes No Test Pressure Drop Across Check Valve#1 1 0.0 psid ®paned at 4,0 psid Final Closed Tight_Yes_No Closed Tight _r Yes No Closed Tight —Yes—No Opened at psid Test Pressure Drop Across Check Valve in psid r .:r'„,, !ii^e�rt,.,) ,,,,3 r,,ini,,oI e: ... , 0:,', : �,thetk t3,et dor'Fire Pr�tection ;,.,e, EST R• �l l..l kid`F.` :'.:!,,, .,.„.e .;,..,,,,),,,..-7.,.,. Check Valve#1 Check Valve#2 Shutoff Valve#2 initial Test Closed Tight „ Yes ,No psid Closed Tight Yes No psid Closed Tight Yes No Final Tes'. Closed Tight Ye: _No psid Closed Tight Yes i No psid C used TIg t _-_Yes_._.No -k al_i,K4',,,4'4ki":I Pre sure V 8teaker(Pv� at;5M Resl.;*. t qt r ,'H` 'r:1* ve 'iT[',1<'. r..W °j; Air Inlet Valve Check Valve Shutoff#2 Failed to Open_Yes�No Closed Tight Yes �__No Initial Test --- Closed Tight Yes No , Opened at_,___„psid Pressure Drop Across Check Valve 01 psid Yes No Final Test Opened at psid Closed es�e Dropt Across Check Valve#1 std Closed Tight —Yes No ............ ...0....7 Describe parts and repairs when needed: j CERTIFICATION: w hereby certify tf�e foregoing information provided try me to o rest and that the taste ce is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714. f)lt TESTERS SIGNATURE L __TEST DATE>Q�-24-19 Aug.25.2019 01:12 PM Interstate Testing 7637555365 #3296 P 11/19 569 0 16_0 Interstate Testing, LLC nu{ P.O. Box 55 Anoka, MN 55303 REGULATED BACKF LOW ASSEMBLY IRBAJ APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit 4) NAME OF BUILDING;,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 Norwich Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612) 503-7498 Oak Parc Heicihts. MN 55082_ Dean Even$on, APPLICANT COMPANY NAME CONTRACTOR LICENSE It CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575 Donr J (753)744-6149_ ADDRESS CITY STATE ZIP EMAIL P.O. Box 55 Anoka MN 55303 interstatetestinq(&,comcast.net TESTER NAME TESTER CERTIFICATION It PHONE Donn Miller I B7.065323 (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 ".1• • fx''4..::.., °.�. Gk,•...•.5��•� � .:tet ��.(r11�,L�O�`W��R ��MC'F�,�l.�,�. �la� 4({ �tr,�. ....\..'s r`\My'C<j '..,c�� t. .+�.....''x .w;4.� ,. .„_. tnstrttl Relocate _Remove —Replace runt S I4 of Raced Device Rebuild X Test 3��,.,,�,+�3 r��` rr , rr *�r Gf^TFr..w:. T.w. i- ,?..",a, �* sk•'y_` F ..,. .� x :.`>�r": Type(check one); L 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 Model# 975XL Serial rx 1298744 Size: 3/4" (inches) System Serviced Location in bldg I.L. Garbage� Rm. Floor a (Room it Garbage � {; s uJedceed it s " tI t paI di edtsc t Pi , pre fk r Palk° - S7T RESULTS ;°' "'. Check Valve 02 Shutoff Valve IQ Check Valve Al Pressure Differential Relief Valve initial Closed Tight ,Yes _No Closed Tight Yes No Closed Tight ,LYes No Test Pressure Drop Across Check Valve#i 9.0 psid Opened at 4.2 psid Final Closed Tight _Yes,..,..No dosed Tight „Yes No Closed Tight _Yrs_,,.No Opened at paid Test Pressure Drop Amoss Check Valve lf], psid k ` �+b1e" h it (give ak halite_ (1 k l) e�ctoi e Pro cti '`'ip TE ENSU 1S . � Wa L f �'�{ Check Valve Jn 1 Check Valve 02 Shutoff Valve Ui 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 psid Closed Tight w Yes No p,y {,�,e t1�(►. If _ +FR sta V B yke ( rye pEM 1. Air Inlet Valve SG Check Valve Shutoff IQ Initial Test Failed to Open _Yes No Closed Tight Yes _No Closed Tient Yes No Opened at d Pressure Drop Across Cherie Valve 41 pskl ClosTight Yes No Final Test Opened at psid Pressure Drop Across Check Valve ill. psid Closed Tight Yes.,.... No IDescribe parts and repaks when needed: 1 CERTIFICATION: I hereby certify the foregoing information provided by me to b t and that the teste d ce is functioning In compliance with State of Minnesota Plumbing Code,Chapter 4714, pr TESTER'S SIGNATURE ....,__,.. TEST DATE: 08-2.4-19