The URL can be used to link to this page

Home My WebLink About2019 Interstate Testing RBA Reports Aug.25.2019 01:16 PM Interstate Testing 7637555365 #3296 P 14/19 interstate Testing, LLC I P.O. Box 55 ncdw P -� Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY RBA APPLICATION FORM EST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit#) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 554$Norwich ParkwayPresbyterian Homes (Boutwell Landing) Dean Evenson (612)503-7498 Oak P, rk. Heiahts. MN 55082, _pian ,veasop APPUCANT COMPANY NAME CONTRACTORUCENSE# CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC PC751575 )onr Miller (763)744-6149 P.O.ADDRESS CITY STAMAIL Box 55 Anoka MND 55303 iZIP n erstatetestinq(c comcast.net TESTER NAME TESTER CERTIFICATION# PHONE Donn Miller B=065323 (763)744-6149 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL fl TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 � ,r . 1 ' ;;1,70.p'1?;o )hipftiCACID 0 1'4 0004.11 i 10cOi ,' ,�,:.� /.`. '`,.ti '`.. ',, _Install Relocate _Remove _Replace and SN#of Replaced Device Rebuild X Test f BACKFLOW A $f ll,•0LY QIIE0.,A11' iii C l ,1'0* ?, :.r.. 4.:, ''', rz `' 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 BreakerSpill Resistant Pressure Vacuum Breaker Manufacturer:\Nilkins Model# 975XL Serial# 1191851 size: 3/4" (inches) system serviced Trash Chute Rinse Location in bide A.L. Trash Room oomFloor# Roor,:m a v)am ri rf SRETS.1 P � •:P. tg ICOMPEAPC B gy` . 44.011jSE N8 L . :V 2` 6. ! .F. ,sAv R�kilo i kki ilii Tync '11I,io!hoduoe4.Pteisuoi `Derectisr,li;eHcote+tlo* RP E$1'.RFst),( 4`.+•F eF»^`n.5M Check Valve#2 Shutoff Valve#2 Check Valve#1 Pressure Differential Relief Valve Initial Closed Tight X Yes _No Closed Tight X Yes No Closed Tight L Yes No TestPressure Drop Across Check Valve#�8.8 psld Operredat,�. psid Final Closed light,,,...Yes.,.rNo i Closed Tight Yes No I Closed Tight _Yes..,_No Opined at psid Test Pressure Drop Across Check Valve p2, psid v _ ,D*ub1e;' 1�etk Va*e o o ..........!c'...Dpt0ttor E„,im,,, Pt ^., •,l , , 1V,�`��.:w� Iw � •Yl\f ,.1 4 �fr•j ` ,„� ,_, � lr.. ,�/ b ,. .•. .v: . Check Valve 41 Check Valve U2 1 Closed Tight Valve$12 Initial Test Closed Tight _,_,Yes No psid , Closed Tight Yes —No psid ght _--Yes No ,,r Final Test Closed Tight Yes No psid Closed Tight Yes No psid Closed Tight Yes No ' ,n,., A 1 r, r, l�016i:iii ,r/ Lt0iafh I1t!Elx,,�P�(Uy�_O±t,'Spf40*titelot V,_$w41Ct: l Oke '.i$R,/'@J•. E1 T `, N. S!l . ,`k l a+` l ',, Aft inlet Valve Check Valve Shutoff-ft 2 Failed to Open _Yes _No Closed Tight Yes No Initial Test _ _ Closed Tight Yes Opened at,,,___psi d Pressure Drop Across Check Valve#1 psid � ..._ No No Final Test ' Opened at psld pry o re Drop Aossa Check Valve tilvie psid Closed Tight —Yes No ..iiii.iiii.m.ioio.o.i.i.......imi.m.m... = Describe parts and repairs when needed: r CERTIFICATION: I hereby certlfythe foregoing information provided by me to ect and that the teste dce eviis functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714. TESTER'S SIGNATURE ” TEST DATE>..Q 4-19 Aug.25.2019 01:15 PM Interatate Testing 7637555365 #3296 P 13/19 b (4Ib /A FILILAJJ Interstate Testing, LLC P.O. Box 55 Anoka, MN 55303 REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS(INCLUDE Apt/Unit ii) NAME OF BUILDING,OWNER/OCCUPANT,CONTACT NAME AND PHONE NUMBER 5600 Norwich Parkway Presbyterian Homes (Boutwell Landing) Dean Evenson (612)503-7498 Oak Park HeiQnts.MN 55982 Dean EyensoO _ APPtJCANT COMPANY NAME I CONTTRACTOF(UCENSE# CONTACT NAME AND PHONE NUMBER Interstate Testing, LLC 1 PC751575 Donn Miller (763744-6149 ADDRESS CITY STATE ZIP I EMAIL P,O. Box 55 Anoka MN 55303 J interstatetestinqacomcast.net TESTER NAME TESTER CERTIFICATION it PHONE Donn Miller B=065323 (763)744-6149 -TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL It TEST EQUIPMENT SERIAL SI TESTING EQUIPMENT CALIBRATION DATE Midwest Instruments 845-5 05090906 01-16-18 + r fr.x� I'�i+ .+��. ; � �'� �,y '`K n �"Y-i,�^/�p�[�'- [{�� .71p�(�!(y��,c�.p,�..,L{:�.,�,�y,�f:1� �° �.. //" 1 ..',, .,fit"C 3�',� ,:JAL •I t ; �' s Yr iY>G"00 1dvokit ANb'tiEt lilt,7�i' '$i' r: ,^T"�' "•''1tin•%:�Fi .46::+..' i, •;A(y1 �Install�Relocate _Remove yR�eplea�ce and/� Stich of Replaced Device Rebuild X Test J �� ' ��.�j,'` , _j# J �r'�.;.ia J+r t N 1C O '4.4 I' �, EtAit,.0 0,614 44 �Y' 1?rt p ?� , � ., �.ri^Kr, ,� ., ,,s.,144 .. _ .. _. � .. ,. Type(cheek 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 Manufacturer.Wilkins Model 975XL Serial it 1191850 Size:314" (inches) System Serviced Boiler Make UP Location inbidg Boiler room Floor Room Boiler ' >ri°w, xES *Mrs's'P !au , ((O kkr,t#APPUC S:ltf0 T'k*A O.iji BEI;+ W ^y�ai) J j . . rJ 7`��J �-� Wn `J � /1 rt �' ��" �` �i f. k ��., �. .1Y c v/+ z r;!§, KadinP ukiF?1 d ,i'k Ret+lc 01:6 ':Deter uv re�'P'cote tion(RP) °TEST RESP'."LTS . y 4 Check Valve It. 1 Shutoff Valve#2 Check Valve#i Pressure Differential Relief Valve Initial Closed light X Yes _No Closed Tight X Yes No Closed Tight L.Yes No TestOpened at 3.5 psid Pressure Drop Across Cherie Valve#19.0 paid Final Closed Tight_Yes_No Closed Tight Yes No Closed Tight _Yes_No Opened at paid Test Pressure Drop Aaoss Check Valve#1 psid f V .�i �S �.� }T�-' 1 J. A 1 .` , k tit.'r �; "n .; :>a 4 ikr4uble Chen t? it4 PiC.E ,4� $e. �ciiC OdteCtoi,-Tire Pt`ote t on.QC .-�T ST AE.SUt i ,,tf g."., Check Valve iii Check Valve 112 Shutoff Valve tt2 Initial Test dosed Tight Yes No psid Closed Tight Yes —No psid Closed Tight _Yes No Fined Test f Closed Tight Yes No psid Closed Tight Yes No psid Closed Tight Yes _No 4 ` ,tr,P1"e U, nt 8 eak PV$1 o>t',Spin:5 sllitaat,Wa*iit lreskertSRVBrvsI O. REsuet4 . ,. :, _ Ah Inlet Valve Check Valve Shutoff ttt Initial Test Failed to Open Yes_PIo osed Cl '1pht _Yes —No posed Tkght Yes No Opened at_ „ ...psid Pressure Drop Across Check Valve IT1 psid Final Test , Clued Tight _Yes _No F Opened at psid Pressure Drop Across Check Valve#1 .. psid Closed Tight ,_..Yes...� No Describe parts and repairs when needed: CERTIFICATION! I hereby certify the foregoing information provided by me to red and that teste de. 'oe is functioning in compliance with State of Minnesota Plumbing Code,Chapter 4714, P114 TESTER'S SIGNATURE TEST DATE: 08-24-19.