HomeMy WebLinkAbout2024-12-19 Commercial Plumbing & Heating RBA Test Report - Irrigation24428 Greenway Avenue
Forest Lake, MN 55025
(651) 464-2988
REGULATED BACKFLOW ASSEMBLY (RBA) TEST REPORT
APPLICANT COMPANY NAME
ADDRESS
TESTER NAME
TEST EQUIPMENT MANUFACTURER
STATE
CONTRACTOR LICENSE #
CITY
CONTACT NAME AND PHONE NUMBER
EMAIL ZIP CODE
PHONE TESTER CERTIFICATION #
TESTING EQUIPMENT CALIBRATION DATE TEST EQUIPMENT SERIAL# TEST EQUIPMENT MODEL#
TYPE OF WORK AND FEE INFORMATION (check one)
Install Relocate Remove Replace and SN# of Replaced Device Rebuild Test
BACKFLOW ASSEMBLY DETAIL INFORMATION
Type (check one): Reduced 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: Model # Serial # Size: (inches)
System Serviced Location in bldg. Floor # Room #
NAME OF BUILDING, OWNER/OCCUPANT CONTACT NAME AND PHONE NUMBER
ADDRESS CITY STATE ZIP CODE
TEST RESULTS: Pass Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW)
Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) – TEST RESULTS
Pressure Differential
Relief Valve Check Valve #1 Shutoff Valve #2 Check Valve #2
Final
Test
Initial
Test
Opened at psid
Opened at psid
Closed Tight Yes No
Pressure Drop Across Check Valve #1 psid
Closed Tight Yes No
Pressure Drop Across Check Valve #1 psid
Closed Tight Yes No
Closed Tight Yes No
Closed Tight Yes No
Closed Tight Yes No
Double Check Valve or Double Check Detector Fire Protection (DC) – TEST RESULTS
Final Test
Initial Test Closed Tight Yes No psid
Check Valve #1
Closed Tight Yes No psid Closed Tight Yes No psid
Closed Tight Yes No psid
Shutoff Valve #2
Closed Tight Yes No
Closed Tight Yes No
Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) – TEST RESULTS
Air Inlet Valve
Check Valve #2
Check Valve Shutoff #2
Initial Test
Final Test
Failed to Open YES NO
Opened at psid
Closed Tight YES NO
Closed Tight YES NO
Closed Tight YES NO
Pressure Drop Across Check Valve #1
Closed Tight YES NO
Pressure Drop Across Check Valve #1
Opened at psid
Describe parts and repairs when needed:
CERTIFICATION: I hereby certify the foregoing information provided by me to be correct and that the tested device is functioning in compliance with
State of Minnesota Plumbing Code, Chapter 4714.
TESTER’S SIGNATURE: TEST DATE:
Joel Parent BF066231 651-464-2988
Melinda WisgerhofCommercial Plumbing & Heating, Inc.PC643117
mwisgerhof@cpandh.com
Midwest Instrument 845-5-11150354
24428 Greenway Ave Forest Lake MN 55025
Static _______ PSI
1/3/24
Goodwill
5890 Krueger Lane N Oak park Heights MN 55082
Apollo RPLF4A 719812 11/2"
Irrigation
7.8 2.4
12/19/24