HomeMy WebLinkAbout2023-12-23 Commercial Plumbing & Heating RBA Test Report 0Fore24428 Greenway Avenue
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st Lake, MN 55025
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REGULATED BACKFLOW ASSEMBLY (RBA)TEST REPORT
NAME OF BUILDING,OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER
Goodwill
ADDRESS CITY STATE ZIP CODE
5980 Krueger lane north Oak Park Heights Mn 55082
APPLICANT COMPANY NAME CONTRACTOR LICENSE# CONTACT NAME AND PHONE NUMBER
Commercial Plumbing&Heating,Inc. PC643117 Melinda Wisgerhof
ADDRESS CITY STATE ZIP CODE EMAIL
24428 Greenway Ave Forest Lake MN 55025 mwisgerhof@cpandh.com
TESTER NAME TESTER CERTIFICATION# PHONE
Clint Pream BF065696 651-464-2988
TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL# TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE
Mid-West 845 11150355 1/6/23
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p TYPE OF WORK AND FEE INFORMATION(check one)
Ilinstall I Itelocate ❑Remove[ (Replace and SN#of Replaced Device Rebuild-Z Test
BACKFLOW ASSEMBLY DETAIL INFORMATION
Type(check one):fr/lReduced Pressure Principal or Pressure Principal Fire Protection I Reduced Pressure Detector Fire Protection
1-1 Double Check Valve 1-1 Double Check Detector Fire Protection Fl Pressure Vacuum Breaker[ (Spill Resistant Pressure Vacuum Breaker
Manufacturer:APOIIo Model#RPLF4A Serial#719812Size:11/2" (inches)
System Servicedirrigation Location in bldg.Water main room Floor# Room#
TEST RESULTS: ✓ Pass ElFail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW)
Reduced Pressure Principal or Reduced Pressure Detector Fire Protection(RP) TEST RESULTS
Check Valve#2 Shutoff Valve#2' Check Valve#1 Pressure Diffevential
Relief Valve
InitialClosed Tight n✓ Yes❑No Closed TightlYes[lo Closed Tight nYes allo 7 8 Opened 2.4 psid
Test Pressure Drop Across Check Valve#1 psid
Final Closed Tight nYes nNo Closed Tight❑Yesnlo Closed Tight❑1' nNo Opened psid
Test Pressure Drop Across Check Valve#1 psid
Double Check Valve or Double Check Detector Fire Protection(DC)-TEST RESULTS
Check Valve#1 Check Valve#2 Shutoff Valve#2
Initial Test
Closed Tight nYesFIN° psid Closed Tight❑Yes[1Vo psid Closed Tightf1n Yes I 1No
Final Test n
Closed Tight I IYesElE n nNo psid Closed Tight Eyes No psid Closed Tight 1 I Yes 1 I No
Pressure Vacuum Breaker(PVB)or Spill Resistant Vacuum Breaker(SRVB)-TEST RESULTS
Air Inlet Vck V hutoff 2
Initial Test Failed to Open YES NO Closed Tight II YES Closed Tight I YES I NO
Opened at psid CNhO PressureYYDrop Across
Final Test Opened at psid Closed Closed Tight I—YES ONO
Pressure Drop Across Check Valve#1
Describe parts and repairs when needed:
CERTIFICATION:I hereby certify the foregoing information provided by me e correct and that the tested device is functioning in compliance with
State of Minnesota Plumbing Code,Chapter 4714.
TESTER'S SIGNATURE: TEST DATE:12/27/2023