HomeMy WebLinkAbout2019-12-20 Regulated Backflow Assembly Test Report Dec.20.2019 04:31 PM Interstate Testing 7637555365 #4018 P 3/ 3
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 BULDINO,OWNER/OCCUPANT,CONTACT NANIE AND P ENUMBER
5600 Norwich Parkway Presbyterian Homes (Boutwell Landing) Dean Evanson (612)503-7498
Oak P�rK Hgights, M1\ X06? Agan Evenson _
APPLICANT COMPANY NAME CONTRACTOR LICENSE it CONTACT NAME AND PHONE NUMBER
Interstate Testing, LLC PC75175 Donp Miller (763)744-6149
ADDRESS CITY STATE ZIP EMAIL
P.O. Box 55 Anoka MN 55303 interstatetesting@comcast.net
TESTER NAME TESTER CEII7lFICATION# PHONE
Donn Miller ,B":065323 (763)744-6149
TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL a TEST EQUIPMENT SERIAL it TESTING EQUIPMENTCAUBRATION DATE
Midwest Instruments 845-5 05090906 01-16-18
u `YPE OF�I O It/SND FE£;INF.OR ATION(check°o de , �,i LL
Install`Relocate —Remove Replace and SNH of Replaced Device Rebuild X Test
�`/�, ,. " r . BACKFLOW ASSEMBL DE AIL INF IRMArIOIV
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 BreakerSpill Resistant Pressure Vacuum Breaker
Manufacturer:Wilkin$ Model# 950XLT Serial;# 2989315 Size:, 1" (inches)
system Serviced Washing Machine Fill Location in wig Laundry Room,Behind Washing MachlneS Floor tower Level Room# Laundry
> „ST REST LTrSt �:� Pass*�rRit �(CO +IPL TE APP�ICE BLE ASSEMB1 Y TYPE SFGTJoN BELOW)
Pressure Differential
Check Valve 112 Shutoff Valve#2 Check Valve#1 Relief Valve
Initial. Closed Tight „ Yes ,..No Closed Tight Yes No Closed Tight _.,Yes . No.
Test Opened at psid
Pressure Drop Across Check Valve#1, psid
final Closed Tight ___Yes_No dosed Tight Yes No Closed Tight .,.,.'Yes_,_,,,No Opened at psid
Test Pressure Drop Across Check Valve ml psid
•
aeu e' hei k vh nr,�o a t eck a+ x 1Ftir+�Pl'tltect qn s1' Irsu>7
Check Valve 41 Check Valve 42 Shutoff Valve tit
Initial Test dosed Tight ,Les No 2.4 psid Closed Tight Yes No 1,6 psid Closed Tight , Yes No
Final Test Closed light Yes _No psid Closed Tight -„-, YesNo psidTight Yes No
Closed
Qsat)t act Wh.8rea1t ` p1rl "lift S' i11 Rk i5t 11 �l3 Ili lr►8't Oker 5 V 5t ftl SUL'7S ,
Air inlet Valve Check Valve Shutoff#2
Initial Test Failed to Open_Yes No Closed Tight Yes _No
Opened at .psid Pressure Drop Across Check Valve Hi psid Closed Tight Yesr No
AnTest Opened at psid Closed Tight Yes_ No
Pressure Drop Across Check Valve#1,.�r�psld Tight Yes.._. No
Describe parts and repairs when needed: 1
r r l
CERTIFICATION/ I hereby certify the foregoing Infomiatlon provided by me to rect and that the teste d 'cc is functioning in compliance with
State of Minnesota Plumbing Code,Chapter4714,
TESTER'S SfGNATIJRE TE5T DATE: 12-2Q-19