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HomeMy WebLinkAbout2019 AIE Inspection Services Backflow Prevention Test Reports Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 5th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess • Date 10-11-19 Oak Park Heights,MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT .v Time 1430 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm co.WM Alarm Central 'w Alarm Phone 497-273-4600 1r Location:Inside v, Describe location(Please be specific): Located in Meat Dept. Usage: Domestic Nr Mfg Model Size Serial# Type 'V Febco ♦ 765 3/4" 976559 Orientation: Vertically Up • Protection: Isolation Nr Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 4-18 Relief ports on RPZ free of continuous discharge? l Installed Pressure Difference Date Double Check Valve Assembly (15t ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE (PVBJSVB J Q i Held at PSID Held at PSID Opened at PSID AIR INLET g- Leaked D Closed Tight ❑ Did Not Open 0 Opened at 2.2 PSID Leaked 0 Did Not Open 0 0 Cleaned ❑ Cleaned ❑ Cleaned 0 Cleaned r„ 0 Replaced: ❑ Replaced: ❑ Replaced: 0 Replaced: re w zi 0 Ili w Air Inlet 2.2 PSID PSID PSID PSID Check Valve 1.6 PSID Closed Tight ❑ Leaked El PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight Xe Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest 'V Model 845-3 Nir Serial # 06190252 'V Last Calibration Date 6-19 El Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy D0,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! DIP Report Rev 0611-All-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess ' Date 10-11-19 Oak Park Heights, MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT ' Time 1415 Phone 651-439-7476 Job# 11(556 Ceti Exp Date 12-31-2021 Alarm Co.WM Alarm Central 14, Alarm Phone 497-273-4600 w Location: Inside Tr Describe location(Please be specific): Located in Produce at Culligan Unit. Usage:Domestic • Mfg Model Size Serial# Type: w Watts 'V 800M4 314" 044351 Orientation: Vertically Up W Protection: Isolation w Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 411) Relief ports on RPZ free of continuous discharge? 'V Installed Double Check Valve Assembl Pressure DifferenceDate y (le ck-relief) N/N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE �VBTSVB E Held at PSID Held at PSID Opened at PSID AIR INLET • Leaked ❑ Closed Tight ❑ Did Not Open ❑ Opened at 1.6 PSID Leaked 0 Did Not Open ❑ 0 Cleaned ❑ Cleaned 0 Cleaned ❑ Cleaned co ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: ccw 0 wm cc Air Inlet 1.6 PSID Z PSID PSID LL PSID Check Valve 1.2 PSID Closed Tight ❑ Leaked ID PASS I FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight X Leaked Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest w Model 845-3 V Serial # 06190252 'V Last Calibration Date 6-19 IX Certification Tag Placed on BFP at Completion of Test [5 1 BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DO,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess 'V Date 10-11-19 Oak Park Heights, MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT '► Time 1345 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm Co.WM Alarm Centrals Alarm Phone 487.273 4600 Location:Inside s Describe location(Please be specific): Located in Produce Dept. Usage:Domestic s Mfg Model Size Serial# Type s Watts s 800M4 3/4" 044435 Orientation: Vertically Up s Protection: Isolation s Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date -18 * Relief ports on RPZ free of continuous discharge? s Installed Double Check Valve Assembly Pressure Difference Date (181 ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB VB E Held at PSID Held at PSID Opened at PSID AIR INLET • Leaked 0 Closed Tight 0 Did Not Open ❑ Opened at 3.2 PSID Leaked 0 Did Not Open ❑ El Cleaned ❑ Cleaned 0 Cleaned ❑ Cleaned u, 0 Replaced: 0 Replaced: 0 Replaced: ❑ Replaced: re Li, ▪0 w2 rt Air Inlet 3.2 PSID PSID PSID LT u_ _PSID Check Valve 2.6 DPSID Leaked L J Closed Tight CI PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight X Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest s Model 845-3 'Ir Serial # 06190252 s Last Calibration Date 6-19 n Certification Tag Placed on BFP at Completion of Test Q BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess 'V Date 10-11-19 Oak Park Heights,MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 'V Time 1330 Phone 651-439-7476 .lob# 1K556 Cert Exp Date 12-31-2021 Alarm Co.WM Alarm Central ., Alarm Phone 497-273-4600 Location:Inside Describe location(Please be specific): Located in Bakery. Usage:Domestic Mtg Model Size Serial# Type: 'V Watts lir 800M4 3/4" 044348 Orientation: Vertically Up 'V Protection: Isolation w Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 4-18 Relief ports on RPZ free of continuous discharge? 'V Installed Double Check Valve Assembl Pressure eifferenDate yNe(15t ck-relief) NIA Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB VB J Q r Held at PSID Held at PSID Opened at PSID AIR INLET Leaked ❑ Closed Tight 0 Did Not Open ❑ Opened at 2.8 PSID Leaked ❑ Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned ,, ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: re Lu Q0 wz PSID PSID Air Inlet 2.8 PSID 7t1ZE. PSID Check Valve 2.8 PSID Closed Tight Leaked El PASS 1 FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight X Leaked Forward Flow Test Performed: If Performed - Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of lest cocks. Test Kit Make Midwest 'V Model 845-3 mv Serial # 06190252 'V Last Calibration Date 6-19 n Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE•DIGITAL EDITION 082211 Please print all information neatly AI E Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd, NE Inspector Lenny Burgess lir Date 10-11-19 Oak Park Heights,MN, St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT w Time 1315 Phone 651439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm Co.WM Alarm Central w Alarm Phone 497-273-4600 IF Location:Inside w Describe location(Please be specific): Located in Deli. Usage:Domestic w Mfg Model Size Serial# Type: w Watts IF 800M4 3/4" 044320 Orientation: Vertically Up w Protection: Isolation w Height off Meter/Acct# Floor 5' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date Relief ports on RPZ free of continuous discharge? w Installed Double Check Valve Assembl Pressure Difference Date Y (151 ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE (ViVB F- Held at PSID Held at PSID Opened at PSID AIR INLET Leaked 0 Closed Tight 0 Did Not Open 0 Opened at 2.4 PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned u, ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: rxm 0 w2 cc Air Inlet 2.4 PSID zPSID PSID a: PSID Check Valve 2.8 PSID El Tight Leaked CI PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 55 Closed Tight X Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: NIA GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest w Model 845-3 w Serial # 06190252 w Last Calibration Date 6-19 C Certification Tag Placed on BFP at Completion of Test 71 BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AlE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess I' Date 10-11-19 Oak Park Heights, MN. St Cloud, MN,56304 Certification! Manager Phone (320)493-8277 License# 090989-BT V Time 1300 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm Co.WM Alarm Central Nr Alarm Phone 497-273-4600 V Location:Inside V Describe location(Please be specific): Located at Front Mop Sink, GM Entry. Usage:Domestic V Mfg Model Size Serial# Type: V Watts V 800M4 3/4" 405492 Orientation: Vertically Up 1r Protection: Isolation w Height off Meter/Acct# Floor 8' (inlft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 2-16 * Relief ports on RPZ free of continuous discharge? 'V Installed Pressure fference Date Double Check Valve Assembly (1s1 ck-relief) N/A Rebuilt N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE �VBSVB J �� Q H Held at PSID Held at PSID Opened at PSID AIR INLET K- Leaked ❑ Closed Tight ❑ Did Not Open 0 Opened at 2.2 PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned f12 ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: ccw 0 wM cc Air Inlet 2.2 PSID z PSID PSID PSID Check Valve 2.4 PSID LL Closed Tight ElLeaked PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note it attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest V Model 845-3 V' Serial # 06190252 'V Last Calibration Date 6-19 n Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print at information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess V Date 10-11-19 Oak Park Heights,MN. St Cloud, MN.56304 Certification! Manager Phone (320)493-8277 License# 090989-BT V Time 1245 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm CO.WM Alarm Central V Alarm Phone 497-273-4600 V Location:Inside V Describe location(Please be specific): Located in Garden Center Valve Room. Usage:Irrigation • Mfg Model Size Serial# Type: Reduced Pressure Zone V Wilkens ' 975RP 2" 037127 Orientation: Horizontal • Protection: Isolation • Floor off 2' (intft) N�Ater!Acct# REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A *Relief ports on RPZ free of continuous discharge?Yes V Installed Pressure Difference Date Double Check Valve Assembly (18t ck-relief) N/A Rebuilt 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB 3I" Held at 7.2 PSID Held at 1.8 PSID Opened at 4.2 PSID AIR INLET Leaked 0 Closed Tight © Did Not Open 0 Opened at PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned 0 Cleaned 0 Cleaned �_ 0 Replaced: 0 Replaced: 0 Replaced: 0 Replaced: ui w2 w re PSID PSID Air Inlet PSID Z it PSID Check Valve PSID Closed Tight 0 Leaked In PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest • Model 845-3 V Serial # 06190252 V Last Calibration Date 6-19 ❑X Certification Tag Placed on BFP at Completion of Test XD BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 83341!Inspector to work PRINTED COPY to STORE for you! SFR Report Rev 0611-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St. N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess IF Date 10-11-19 Oak Park Heights, MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 'V Time 1230 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alarm co.WM Alarm Central v• Alarm Phone 497-273-4600 Location:Inside Describe location(Please be specific): Located at Back Mop Sink. Usage:Domestic Mfg Model Size Serial# Type: Watts 'V 800M4 3/4" 403973 Orientation: Vertically Up 'V Protection: Isolation w Height off Meter!Acct# Floor 8' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date 2-16 • Relief ports on RPZ free of continuous discharge? II Installed Pressure Difference Date Double Check Valve Assembly (1st ck-relief) N/A Rebuilt _ N/A CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE 03VB VB a P. Held at PSID Held at PSID Opened at PSID AIR INLET Leaked ❑ Closed Tight ❑ Did Not Open 0 Opened at 1.6 PSID Leaked 0 Did Not Open 0 ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned r„ ❑ Replaced: ❑ Replaced: ❑ Replaced: ❑ Replaced: CC 1.1.1 0 w2 cc Air Inlet 1.6 PSID z PSID PSID LL PSID Check Valve 2.2 PSID Closed Tight ❑ Leaked d PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks, Test Kit Make Midwest " Model 845-3 Serial # 06190252 'V Last Calibration Date 6-19 n Certification Tag Placed on BFP at Completion of Test n BFP in Service Inspector's Signature Customer Signature Print Name & Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE.DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd.NE Inspector Lenny Burgess 1r Date 10-11-19 Oak Park Heights,MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 1r Time 1215 Phone 651-439-7476 Job# 1 K556 Cert Exp Date 12-31-2021 Alarm CaVVMCoAlarm Central V Alarm Phone 497-273-4600 V Location: Inside V Describe location(Please be specific): Located in Riser Room. Usage:Fire V Type: Double Check Mfg Model Size Serial# YP Ames V 3000SS 8" 137787 0205 Orientation: Horizontal V Protection: Containment V Height off Meter/Acct# Floor 4' (iNft) ,NJAe REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A Relief ports on RPZ free of continuous discharge? V Installed Double Check Valve Assembly Pressure Differs ck-relief) A Date Rebuilt (1 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB L Held at 3.6 PSID Held at 2.8 PSID Opened at PSID AIR INLET Z Leaked 0 Closed Tight lEl Did Not Open 0 Opened at PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned 0 Cleaned 0 Cleaned a _ 0 Replaced: ❑ Replaced: 0 Replaced: 0 Replaced: rew a w PSID PSID z Air Inlet PSID LL PSID Check Valve �P-SIID Closed light ❑X Leaked f PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight j( Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: N/A GPM Actual Flow Rate: NA GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest V Model 845-3 V' Serial # 06190252 V Last Calibration Date 6-19 ® Certification Tag Placed on BFP at Completion of Test © BFP in Service Inspector's Signature Customer Signature Print Name &Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE, 1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0811-AIE-DIGITAL EDITION 082211 Please print all information neatly AIE Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd. NE Inspector Lenny Burgess 'V Date 10-11-19 Oak Park Heights,MN. St Cloud, MN.56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT 'V Time 1200 Phone 651-439-7476 Job# 1 K556 Cert Exp Date 12-31-2021 Alarm Co.1 M Alarm Central 'V Alarm Phone 497-273-4600 Location:Inside Describe location(Please be specific): Located in Riser Room. Usage:Fire Nr Mfg Model Size Serial# Type: Double Detector Check-Bypass 'V Ames 'V 2000B 3/4" 41196 Orientation: Horizontal Protection: Containment Height off Meter/Acct# Floor 4' (in/It) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date N/A Relief ports on RPZ free of continuous discharge? 'V Installed Double Check Valve Assembly (1 P�ssure Difference Date 4-18 ck-relief) N/A Rebuilt CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB 4 Held at 1.2 PSID Held at 1.4 PSID Opened at PSID AIR INLET z Leaked 0 Closed Tight © Did Not Open ❑ Opened at PSID Leaked ❑ Did Not Open ❑ ❑ Cleaned 0 Cleaned 0 Cleaned 0 Cleaned CD ❑ Replaced: ❑ Replaced: 0 Replaced: 0 Replaced: rw w2 ct IPSID PSID Air Inlet PSID w PSID Check Valve PSID Closed Tight Q Leaked ❑ PASS ✓ FAIL No.2 Shutoff Valve Supply Pressure 50 Closed light X Leaked Forward Flow Test Performed: If Performed- Designed Flow Rate: N/A GPM Actual Flow Rate: N/A GPM Note: Include hose stream demand where applicable Please note if attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest v Model 845-3 Serial # 06190252 'V Last Calibration Date 6-19 ® Certification Tag Placed on BFP at Completion of Test ® BFP in Service Inspector's Signature Customer Signature Print Name &Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're fired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0811-AIE-DIGITAL EDITION 082211 Please print all information neatly AI E Inspection Services, Inc. Backflow Prevention Assembly Test Report Inspected By Store# WM-1861 Company Quality Design&Fire Address 3400 55th St.N.W. Address 780 Mayhew Lake Rd, NE Inspector Lenny Burgess V Date 10-11-19 Oak Park Heights,MN. St Cloud, MN. 56304 Certification/ Manager Phone (320)493-8277 License# 090989-BT " Time 1145 Phone 651-439-7476 Job# 1K556 Cert Exp Date 12-31-2021 Alar CoWM Alarm Central Alarm Phone 497-273-4600 w Location: Inside V Describe location(Please be specific): Located in Riser Room. Usage:Domestic V Mfg Model T Size Serial# Type: Reduced Pressure Zone V Watts V 909 3" 179856 Orientation: Horizontal V Protection: Isolation Height off Meter/Acct# Floor 4' (in/ft) N/A REDUCED PRESSURE PRINCIPLE ASSEMBLY Date *Relief ports on RPZ free of continuous discharge?Yes V Installed N/A Double Check Valve Assembly Pressure Differen A Date (15'ck-relief) Rebuilt 4-18 CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB Held at 6.4 PSID Held at 2.6 PSID Opened at 3.2 PSID AIR INLET g Leaked ❑ Closed Tight ❑X Did Not Open 0 Opened at PSID Leaked 0 Did Not Open ❑ ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Cleaned to , ❑ Replaced: ❑ Replaced: 0 Replaced: 0 Replaced: cc m z PSID PSID Air Inlet PSID a PSID Check Valve PSID Closed Tight El Leaked d PASS ' FAIL No.2 Shutoff Valve Supply Pressure 50 Closed Tight X Leaked Forward Flow Test Performed: If Performed-Designed Flow Rate: NIA GPM Actual Flow Rate: NIA GPM Note: Include hose stream demand where applicable Please note tf attempted cleaning,flushing or unclogging of test cocks. Test Kit Make Midwest V Model 845-3 V' Serial # 06190252 V Last Calibration Date 6-19 ® Certification Tag Placed on BFP at Completion of Test 0 BFP in Service Inspector's Signature Customer Signature Print Name &Title 1314 Hwy DD, Defiance, MO 63341 (636)398-5288 Fax:(636)828-4634 We're tired up Distribution: DIGITAL COPY to AIE,1314 Hwy DD,Defiance,MO 63341/Inspector to work PRINTED COPY to STORE for you! BFP Report Rev 0611-AIE-DIGITAL EDITION 082211