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HomeMy WebLinkAboutRPZ-backflow preventer reports E�� Ce�ebrating 50 Years �� TM Owens Companies, Inc. ��T�e GON�1 fOYt �� 930 East 80th Street Bloomington, MN 55420-1499 952.854.3800 FAX:952.854.3769 www.owensco.com June 11, 2014 R�C�/�/�D i f rono C JUN �2?0�4 c ty o o /�, Attention: Lyle OF O/�� P.O. Box 66 NO Crystal Bay, MN 55323 Attached are copies of the Annual RPZ Test reports for 2500 Shadywood Road, Navarre. Two are Freshwater Foundation and two are Cargill Freshwater Research. Sincerely, OW NS C PANIES, INC. �,//., J f"/ / 4C/- r � Lee Cohan Administrative Manager Attachment Building Services• Engineering • Water Treatment Mechanical Contracting • Automation • Home Comfort OWENS TECHNOLOGY COMPANIES Locally Owned• Nationally Recognized • Since 1957 An Equal Opportunity Employer oUJE�15 � OWENS COMPANIES, �N�. BACKFLOW PREVENTER 930 East 80`"Street TEST REPORT Bloomington,MN 55420-1499 - 952-854-3800 Fax:952-854-3769 �, � www.owensco.com �RL�!-�WA-�'2'� ��+4�t-►>la�.� \ Locally Own�d�- Nafionally Recognized- Since 1957 Work Order Number: ��'�,,7 Date: � � Name: i1� '�--1\ A�y+> Home Phone: Address: � �� 1 ' "�v'� Work Phone: Ci , State,Zi : ' ,A- Cell Phone: Location of service if different: ^ �L � � f� Email: Make and Model of Device: -�� , � Size: � Serial No.: Check Valve#1 Check Valve#2 Pressure Differential Pressure Differential Strainer , �} Across#1 when Relief Opens Test Befo�e Leaked ❑ Leaked ❑ None ❑ Repair P.S.I. P.S.I. Closed ❑ Closed ❑ Cleaned ❑ Describe (� 1lp� Repair: � p�.� � 'U�V'� '-� J � Leaked ❑ Leaked ❑ Final Test ��� P.S.L `� P.S.I. - Closed ❑ Closed ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: Replaced: ❑ Replaced: ❑ Replaced: ❑ � Disc ❑ Disc ❑ Disc: ❑ � Spring ❑ Spring ❑ Upper ❑ Guide ❑ Guide ❑ Lower ❑ Pin Retainer ❑ Pin Retainer ❑ Spring ❑ 'o Hinge Retainer ❑ Hinge Retain�r ❑ Diaphragm: ❑ m E ❑ , � Seat ❑ Seat ❑ Large: a ` Diaphragm ❑ Diaphragm ❑ Upper ❑ °' ❑ ❑ Lower ❑ � ❑ ❑ Small ❑ ❑ I ❑ Seat: ❑ ❑ 1 ❑ Upper ❑ ❑ �_❑ Lower ❑ ❑ �_❑ Spacer: ❑ � _t� Lower ❑ .--;• Final Test Opened at_Ibs Closed Tight Closed Tight �. Reduced Pressure ` Initial Test By: Date: �. Repaired By: � Date: Final Test By:�� �j� �'������ Date:������� A183-0613 ouuEns � OWENS COMPANIES, �N�: BACKFLOW PREVENTER 930 East 80`h Street TEST REPORT Bloomington,MN 55420-1499 - 952-854-3800 Fax:952-854-3769 i" '� i � www.owensco.com �('�S F��„1 k-T� �tx��-rr'�a� Locally Owned- Nationally Recognized- Since 1957 Work Order Number: � Date: \ Name: � � �� ` �� Home Phone: Address: � � Work Phone: Ci , State,Zi : � (� '� Cell Phone: Location of service if different: �' 6 � � Email: Make and Model of Device: Size: � '' Serial No.: L.� ( , Check Valve#1 Check Valve#2 Pressure Differential Pressure Differentiai Strainer , �` Across#1 when Relief Opens Test Befo�e Leaked ❑ Leaked ❑ � None ❑ Repair P.S.I. P.S.I. Closed ❑ Closed ❑ Cleaned ❑ Describe ����� r�U�� �� Repair: Leaked ❑ Leaked ' ❑ Final Test r�' �� P.S.I. � � P.S.I. Closed ❑ Closed ❑ ��` 1...-' `--� Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: Replaced: ❑ Replaced: ❑ Replaced: ❑ CDisc ❑ Disc ❑ Disc: ❑ � �- Spring ❑ Spring ❑ Upper ❑ Guide ❑ Guide ❑ Lower ❑ Pin Retainer ❑ Pin Retainer ❑ Spring ❑ 'o Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ d E � Seat ❑ Seat I ❑ Large: ❑ m a � ` Diaphragm Diaphragr� Upper °' ❑ ❑ Lower ❑ m � ❑ �_❑ Small ❑ ❑ �_❑ Seat: ❑ ❑ I� ❑ Upper ❑ ❑ �❑ Lower ❑ ❑ �_❑ Spacer: ❑ � � Lower ❑ Final Test I Opened a _Ibs Closed Tight � Closed Tigh4 Reduced Pressure � Initial Test By: Date: Repaired By: � Date: Final Test By:�`�� \--�(��'� ���v���� Dat��,"�G�"1 A183-0613 I ����� REV TER OWENS COMPANIES, �N�. BACKFLOW P EN 930 East 80t"Street TEST REPORT Bloomington,MN 55420-1499 ;,� 952-854-3800 Fax:952-854-3769 � �� www.owensco.com �L� � Locally Owned- Nationally Recognized- Since 1957 Work Order Number: Date: �" � ° � � Name: � � �c�'�i��Y.�� Home Phone: Address: ��� � � �'� ' Work Phone: Cit ,State,Zi : ��, , , �, } Cell Phone: Location of service if different: •� ��. -�p� ., mail: Make and Model of Device: \ � � Size: t -�°' Serial No.: , � �} Check Valve#1 Check Valve#2 Pressure Differential Pressure Differential Strainer � Across#1 when Relief Opens Test Before Leaked ❑ Leaked ❑ None ❑ Repair P.S.I. P.S.I. Closed ❑ Closed ❑ Cleaned ❑ Describe �„T,�_ � �� `�l��J ����� Repair. '—�y +��;�v U Leaked ❑ Leaked ❑ �� '�"� Final Test �,� P.S.I. / � P.S.I. Closed ❑ Closed ❑ �`� Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: Replaced: ❑ Replaced: ❑ Replaced: ❑ Disc ❑ Disc ❑ Disc: ❑ r ) ❑�'�__-�" Spring ❑ Spring ❑ Upper Guide ❑ Guide ❑ Lower ❑ • Pin Retainer ❑ Pin Retainer ❑ Spring ❑ � Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ ,t Seat ❑ Seat II ❑ Large: ❑ m ❑ °' ❑ Upper ` Diaphragm ❑ Diaphragm d ❑ ❑ Lower ❑ � ❑ �❑ Small ❑ ❑ �❑ Seat: ❑ ❑ �I ❑ Upper ❑ ❑ I ❑ Lower ❑ ❑ �❑ Spacer: ❑ � �� Lower ❑ � ' Opene Ibs Final Test Closed Tight Closed Tight I � Reduced Pressure (, ) Initial Test By: I Date: `�, Repaired By: , Date: Final Test By� \�� �c o7 l��i". s� ``=�'7����`v Date: �-�" L" ���` `=V A183-0613 ouuEns ' OWENS COMPANIES,�N�: BACKFLOW PREVENTER 930 East 80`"Street TEST REPORT Bloomington,MN 55420-1499 ,-- 952-854-3800 Fax:952-854-3769 � www.owensco.com �(�!(�L - Local/y Owned- Nationally Recognized- Since 1957 Work Order Number: Date: � Name: `' � `. Home Phone: Address: � <sU [� Work Phone: Cif , State,Zi : A Q�' �"�' \ Cell Phone: Location of service if different: . }4-cw--��e2.�a� Email: Make and Model of Device: i�./� "'�� Size: Serial No.: � Check Valve#1 Check Valve#2 Pressure Differential Pressure Differential Strainer , �' , Across#1 when Relief Opens Test Before Leaked ❑ Leaked ❑ None ❑ Repair P.S.I. P.S.I. Closed ❑ Closed ❑ Cleaned ❑ Des�cribe ��� � �j��U�� G-�7'"�„ Re air: �, ��� Leaked ❑ Leaked ' ❑ .�,. , {�� Final Test ❑ � f � P.S.I. � / �' P.S.I. Closed ❑ Closed � � �'��� � Cleaned ❑ Cleaned ❑ Cleaned ❑ Comments/Materials Used: Replaced: ❑ Replaced: ❑ Replaced: ❑ Disc ❑ Disc ❑ Disc: ❑ � � S rin ❑ �--- p g ❑ Spring ❑ Upper Guide ❑ Guide ❑ Lower ❑ Pin Retainer ❑ Pin RetainQr ❑ Spring ❑ � Hinge Retainer ❑ Hinge Retainer ❑ Diaphragm: ❑ m E ❑ � Seat ❑ Seati ❑ Large: m a � ` Diaphragm Diaphragr� Upper °' ❑ ❑ Lower ❑ � ❑ �❑ Small ❑ ❑ �❑ Seat: ❑ ❑ �_❑ Upper ❑ ❑ �❑ Lower ❑ ❑ �❑ Spacer: ❑ ❑ ❑ Lower 0 ---�, ° Opened a ' Ibs Final Test Closed Tight � Closed Tigt�t ` — Reduced Pressure ( � Initial Test By: Date: � Repaired By: Date: FinalTestBy: 1c_ �C. �--;11�' �� �t��� Date: ��--; (�"�1� A183-0613 ' I MAY/20/2013/MON 09:34 AM Yale Mechani�al FAX No. 952-884-0295 P. 002 � .,. � � �� M E C FI A N I G A l, HVAC-pIPING-5HEETMETA�..MI4lWRIGHT•PLUMDWG BACKFLOW PREVENTQR (RPZ) TEST REPORT JQB ADDRESS= , WORK OFtD�R �C�O .s�� � �� � � � �� 7 OWIVER/OCCUPANT/CONTACT PERSO : CONTACT PHONE� �t' � �� � ��.r a D�VIC��OCATlaN: FLAOR#: ROOM#: h.• � � �o .1�.'< �-.c?�`r'"� SERVES WHAT SYSTEAIf: � t c1-s� MAKE: MODEL,#: SIZE: SERIAL#: � � ,S �d �'" p2`��l `�(I.� INSTALL Dp7�(MONTH/DAY/YEAR): OVERHAUL DATE TEST DATE 1 �.�. (MONTFUDAY/YEAR): (WIONTWDAY/YEAR): (DO NOT PUT A FIJI'UFi�qATE IN ,ec� � rH�s sox} 5'- - ( #1 CHECK VALVE REUEF #2 CW�CK VALYE PSUDIFF PSUDIFF TFST BEFORE REPAIRS FINAL TEST �. �, � � . 7 ✓ DESCRIBE REPAIl2 I�qNY{IF THIS 1S A NEW INSTALLA ON AND REPLACES AN EXISTING DEVICE,INDICATE THE SERfAL NUMBER OF THE DEVICE REMOVED): TEST DON�gY(p��ASE PRINT FIRST&ULST NAM�): GEFi'1'IFICATIdN NUMBER: Gh�rNs Nynes 0�33Q5B� Iwaking errH Ings Work�etle�Since]�'.��9 . � MAY/20/2013/MON 09:34 AM Yale Mechani�al FAX No, 952-884-0295 P, 003 � � � � M ECtiAN I CAL HVAC•PIPING�SHCET ME"I'AL•MILLWR�GN7.p�„UMBING BACK�LOW PR�VENTOR (RPZ) TEST REPQRT JUB ADDRESS; WORK ORDER �`s�p s�� w� / 3 9 3 � 7 OWNEFUOCCUPANT/CDM'ACT PE ON: CON'TAC7 pHON�: �r ,'�t DEVICE LOCATION: FLOOR#: ROpM#: t l'fi� �t)'�'�''� 5�RVES WHAT SY3TEAA: �-�u � ARAKE: MOD�L�: SIZE: SERIAL#: �J t 1�,�� ��sx� � �a�o� INSTALL hAT�(MONTH/DAY/YEAR): OVERHAUL DATE TEST DATfl (MONTH/DAY/Y�}: (MONTH/DAY/YEAR): �►ti Y'` TH SNBOOT�UTA FUTURE DATE IN �T ��� #1 CHECK VpLVE RELIEF #2 CHECK VALVE PSUDIFi� PSI/DIFF TEST B�FORE REPAIRS � ►. FiNAI.T�ST `�• � a, � 7� y� DESCRIBE FtEpAIR I�ANY pF THIS IS A NEW INSTAL TION AND R�pLqC�S AN EXISTING DEVICE,INDICATE THE SERiAL Nl1MB�p OF THE DEVICE REMOV�D): ���.� � � a�k�/,��n � �fws�, ���;S, ,���� ��, 7EST[7pIdE BY(PLEASE PRINT FIRST&LAST NAME): CERTIFICATIOId NUMBER: Chris Hynes Q63305BF Making Ba fdings Work Betrer Ser�r��.��9 � -... MAY/20/2013/MON 09:34 AM Yale Mechanic�l FAX No, 952-884-0295 P, 004 , � � �� M � C H A N I C A L HVAC•PIPMIG•SHEET METAL•MILLWRfGNT-PLUM9ING BAC�FL4V11 PRE!VENI'OR {RPZ) TEST REPORT JOB ADDRESS: WpRK OFiD�R �s�� s �3� � 3 y OWN�p/OCCUPANT/CbNTACT P RSON: CONTACT PHONE: ` l1 s DEVICE LOCA710N: �LOUR#: ROOM#: ���� S�RV�S wHnT sYs7Ea�: d38: ec L� -� ���o �oc.l�. d�c �� �v� 4�tis� MAKE: MODEL iG: St2E: SERIAL#: r' �7 � 3 7�v �� INSTALL DA7'E(141pN7WbAY/YEAR): OVERHAUL DA TEST DATE (MONTH/DAY/YEAR): (MON7WqAY/YEAR): (DO NOT PU7 A KIJ'I'URE DATE IN � THIS BO� � � �' #!1 CHECK V V� RELIEF #2 CHECIC VALV� PSI/DI PSUDIFF TEST BEFORE REPAIRS FINAL 7ES7 �� 3 � �, f �7� � DESCRIBE REpAIR IF ANY(IF THIS IS�1 NEW INSTALL TION AND REPLACE3 AN�XIS7INFG bkVIC�,IPIDICATE THE SERIAL NUMBER UF THE DEVICE REMOVED): TEST DOPIE BY(PL�AS�PRINT FiRST&LAST NAME) CERTIFICATION NUMBER: Chris Hynes 063305BF Making Bu Idings Work Better�dn�e 1939 . � MAY/20/2013/MON 09:34 AM Yale Mechanic�l FAX No, 952-884-0295 P. 005 ' , � � �� M E C H A N I C A L HVAC�PlPING.5HEET pqE7Al.�MI4LWRIGHT•PLUM8ING BACKFLOW PRE'VENT�R (RPZ) 7'EST REPORT JOB ADDRE$$: WORK pRDER so .s` � � � � 3 �' QWNER/�CCUPANT/CaNTACT PER QN: CONTACT PHONE: � 1 l DEVICE LpCA71�N: FLpOR�f: ROOM#: ca a..� �a-�--� � 4 c�� �.s $�FiVES WNAT SYST�AA: ' � MAKE: MOpEI.#: SIZE: SERIAL�: � ` k�� ' 9�sx� �� � � INSTALL DATE(MpN'1'FUI7AY/YEAR): � OVERHAUL DATE DATE (AAON7H/DAY/Y�AR): (AAONTH/DAY/Y�p�); !7^� ��r T��p�UT A FUTURE DA7E IN o` �= 7-1 #1 CH�CK V VE RELIE� al2 CHECK VALV@ PSI/DIFF P5UDlFF TEST��KORE iiEPA1RS FINAL TEST '7. �1 �. �7 DESCRfBE REPAIR IF ANY(IF THIS 15 A NEW INSTALLA pN qNp REPLACES AN EXISTING DEVlCE,INbICA7'�7HE SERIAL NUMBER OF TFlE DEVlCE REMOVED}: TEST DONE BY(PI,�ASE PRINT FIRST&LAST NAAAE): CER'1'I�ICA7101V NUMBER: Chr�s Hynes �� 0633p5�� Making Duil ing�1Alork Better 5ince]�9�9 JUN/07/2012/THU 09; 42 AM Yale Mechanical FAX No, 952-884-0295 P. 001 � � � �� M � C HAN I CAL �� HVAG•PIPING�SHEE7 METAL•MILLWRIGNT•PLUMBING ' � t BACKFLOW PREVENT4R (RPZ) TEST REPORT JOB ADDRESS; WORK ORDER �� S ��-� 1�4'6�� OWNERlOCCUPANT/CONTACT PER N: CONTACT PHONE: n .;( l � _ _ _ DEVICE LOCATIOId: FLOOFi�k: ROOM#: � (� � vC a-a�-wti �-•L. SERVES WHATSYBTEM: �le.�-�;� s s��. MAKE: MODEL#: SIZE: SERIAL#: � �' � k � � �'�� , ,� � 4' INSTALL DATE(MONTWDA1f/YEAR): RHAUL DATE T�ST D 7� (M�NTFUDAY/YEAR): (RAONTH/DAY/YEAR): / (DO NOT PUT A FUTURE DA7E IN ' n�rs eo� ��/ l �'t CHECK VA V� FtEUEF #2 CHECK VALVE PSWIFF PSUDIFP TEST BEFORE REPAIRS F1NAL.TEST � �. � �. � c�ds� . DESCRIg�REPAIR(P ANY(IF TNI5 IS A NEW 1NSTALLA ON AND REPLACES AN EJCI NG D E,IN CAYE 7H�S�Fi AL MB�R OF THE DEVICE REMOVED): T�ST pONE BY(PLEASE PRINT FlRST&I.AST NAIWE): CERI7FICa710N NUMBER: Chris Hynes � 063305BF �� �I � Making Build�ngs Work Better 51nce 1939 JUN/07/2012/THU 09: 43 AM Yale Mechanical FAX No, 952-884-0295 P, 005 .. �. � r �S'._.. �� M E C H A N I C A L t HVAC•PIPIN�•SHE�T MCTA�•MI4lWRiGHT•PLUMElING ����1 �� BACKFLOW PREV►ENTOR (RPZ) T'EST' REPORT JOB ADDRESS: ' WORK ORDER �SdC� S � wao�l r�a � � � �O 7� OWNER/OCCUPANTlCON7'ACT PER N: CQNTACT PHONE: _.., ;_.� Q '( � �c es�,w �..-�e� _ DEVICE LOCATION: FLOOR#: #: �. � L . �� �1�� ��.�-r SERVES HAT SYSTEM: � �� t�a-r MAKE: MOpEL#: SIZE: SERIAL#�: o��s 90 � a°` ���I � i � INSTALL DATE(MO D Y/YFJ1R): OVERHAU�DATE 7ES7 bA7� (MONT�UDAY/YEAR):�a�l� (AAONTFUDAY/YEAR): (DO NOT PUT A FUTURE DA7E IN THIS BO� �F1 CHECK VAWE Ii�U�F #2 CHECK VALVE PS�lDI�p PSI/DIFF TEST BEFOR�R�PAiI�S /�a d�:� FlNAL TEST L(J r o�, � �I � DESCRIBE REP R (IF 7 S IS A N 1NSTALLA N AND REPLACES AN EXI G C ,I IC 7 TH�S�RIAL N 8ER OF 7HE DEVICE REMOVED): �h s�-�. � 1 R�..�b �•��- �- � �r r ���1�9 I TE3T DOPIE BY(PLEAS�PFtINT FIflS7�C LAST NAME): CERTIFICATION NUMBER: Chris Hynes 063305BF i, Maki�g 6uild�ngs Work Better 5ince 19�9 JUN/07/2012/THU 09; 16 AM Yale Mechanical FAX No. 952-884-0295 P, 001 , � � � M � C HAN I CAL ,S'�- HVAC�PIPIN6�SHEE7 ME7A�•MILLWRIGHT*PL,UM8INC� � �!e(h� Y BACKFLOW PREVENTOR (RPZ) TEST REPQRT JOB ADDR@SS: WORK ORDER oZ�S� sl�,a.� �� �� 102� C��'0 OWId R/OCCUPANT/CONTACT PER N: GO TAC'('pHONE: __ �` t�-C` � 1� J C"G'S�ti�.l�,,�.e,r DEVICE LOCA710N: FLOOR�: R00 #: S ll � 0 � � SEF�V�S WHAT SYSTEM: � fa MAKE: MODE �: SIZE: SERIAL#: �C �/l t ('�.S ��5r�h a 3�7aa� INSTALL DA E(MONTFWAY/YEAN): OVEpHAUL DATE TES'I'DA7� ' (MONT'H/DAY/YEM): (AAON'TH/DAY/YEAR): TH S gQ�UT A FUTURE DATE IN �_I ��, � #1 CNECK AL E RELfEF i12 CHECK VALVE PSUDIFF PSNDIF� TE$'T�EFORE REPAIRS FlNAL 7 I .. . _.. . . . . .. . �, � � 3. �� ���s�� DESCRI REpAIFt I�qNY(IF THIS IS A NEW INSTALLA b R�pI,.qCES AM EXISTING DEVICE,I CA S� IAL N MBER OF THE DEVICE REMOVED): TEST DONE BY(PLEASE PRINT FIRST&LAST NAQAE): CERTIFICA710N{dUMBER: Chris Nynes 063305BF Making Bulldings Work Better�inc�ig�9 JUN/07/2012/THU 09: 16 AM Yale Mechanical FAX No, 952-884-0295 P, 002 � � � � L hIECHANiCAI. � S"C_ IiVAC•PIPIN�■SHE�T MCTAL•MIt,LWRIGHT•PLUMBING ��6.� BAGKFLQW PRE�'ENTOR (RPZ) TEST REPORT JOB ADDRESS: WORK ORDER ��On � �.� �.����� �f�a�..�, 1� �l(� �� OWNER/OCCUPANT/CONTAC7 p�Fi ON: CONTACT PHONE: , � � _ � � , __ -._ . Q_(" � �t ,��"�M�,��' DEVICE LOCA110N: FLOOR�: fi00M�: �.`f'" � �-� �• c����� SERVES WHA7 YSTEM: 'e MAKE: MODEL i�: SIZE: SERIAL#: `C.�c �le,'�, �s �75" � ��3`7 `►''T INSTALL DATE O TH/DA /YEAR): OV H L DA7 TEST DATE (MONTH/DAY/YEAR): (AAOM'H/bAY/YEAR): (DO N�T PUT A�UTUFtE DATE IN �p THIS BO� S`��(d"� a #1 CHECK VALVE RE WEF #2 CHECK VAL B PSI/DI�F PSUDIFF TE3T BEFOR R�PAIRS . FlNAL TEST ,, . "�,.. � . . . �� C,o G'�s�� . .. . . DESCRIBE REPAIR IF ANY(IF T ! IS A N�11N INSTALLATIIDN AND REPLACES HXIS1'ING pEVICE.IPIDICATE THE SERIAL NUMBER O�THE DEVICE REMOVED): I TEST DONE BY(PLEA3E PRINT�IAS7&LAST NAM�: CERTIFICATION NUMBER: Chris Hynes , 0633058� � ''� Making Buiid�ngs Work Better Since 1�3J 08/31/2016 09:02 9529143273 MMC PAGE 05 , . ' s ' ANNUA►L. TESl'ING OF RPZ VAIVES ,�QB ApQR�SS: CITY: STATE: zIP CODE; ,Z�04 S1��d .�ce�. �d �c J a ri'�. /�� .�S.�3' I OWNER/OCCUPAI�T: tLDINC NAME; OESCRIPTION OF WORK: ANNUAL �.n����` INSTALL AI,TER REPAIR REPLACE OVERHAUI c�i� ` r`'�t3 CONTACT PERSQN: TE P ONE �iUMBER: C�.��s ��a 4� 9.�� -�7/ 9 773 SYSTEM SERVED: DEVICE LOC,�ITION: FL.O��: ROOM#; ik? � �C�'�.z 1 �� .Cr��aec .lxv�.� MAK.� MODEL: � SIZE: RI #; t���tk��s � �' 7 ��- I " 7 2.9 o g� T ST 7 : OYERHAUL DATE; INSTALI DATE: PREVI V A �Q,�TE: � ZO I� � �3 pE3 CHECK VALVE CHECK VALVE PRES.DIF. ACROSS PRES. DIF. WH�N STRAINER 2.`'� NUMBER 1 NUMBER 2 NUMBER 1 CHECK RELIEF OPENS INITIAL I,EAKED LEAKED e� NONE TEST: CLOSED CLOSED I `� pSl ��� PSI LND INITIAL TEST PASSED, SU6MIT AS FINA� IN►T�;��tEST FA14�D, REPAIR NEEOEO DESCRIBE REp�tl : � ��� ^—'� CMECK VALVE CHECK VA►LVE PRES.DIF. ACRQBS F'RES. nIF. WHEN ^. NUMBER 1 NUMBEf�2 NUMBER 1 CH�CK REUEF OPENS FINAI TEST: CLO5ED LOSED _ Pal i � PSI TEST PERFORMED BY; �F271F!cAT?'^�v�!I►MBEF�' �4ut.4 �� 2QQ�,;B ; . �,M�ANY NAME: COMPANY AD�RESS: CITY ,�TA� '�F`�„�j,� TELEPNONE NUMBER: METROPOLRAN 7340 WASHIN(3TON EDEN MN i 553dd 952.941.7010 MECHANICAL CONTRACT�RS AVENtJE SOU7H PRAIRI� , 08/31/2610 09:02 9529143273 MMC PAGE 01 ( ' ' � �'AX,� COVER SHEET �ROM METROPOLZTa1v 11�ECAANicAL COrrrR.A�,CTORs,XNC. 7340 Waskaivagton Ave�ue South■Edcn Picairie,Mina�esota 55344-3582 Phone: (952)941-7010•Fax: (952)941-9118 Date: 8/31/10 Company Citv of O�rano Attention LYIe Fax 952-249-4616 Regarding RPZ test r�ports Numb�r o�Pages(Including Cover Sheet) 5 a RPZ test reports for 2500 Shadywood Rd Freshwatcr Institute Thanks, Steve Walter Metropolitan Mechanical Contractors Office: 952-914-3267 Fax: 952-914-3273 steve.walterCa7_metromech.corr�, � i � 08/31/2010 09:02 9529143273 MMC PAGE 62 ANNUAL,TESTING OF RP2 VA�.VES JOB ADDRESS: CITY: STpTE: ��, CODE: ,�25'ao .�I,� w«�c� le� /U���r� /�I N ss.�.�1 QWNER/OCCUPA ; ,�UI DI �,r�AM€ DESCRIPTION OF WQRK: ANNUAL � t I r ��� INSTALL ALTER REPAIR REPLACE O RHAUL 1 CONTACT PERSON: T�LEPHONE �1�11���R; ��S i g 1 �'� � q.s� �7� � 7�,� M S RV • ` DEVICE LO ATIO � FLOOR#: RQOM#,� r���� �9 /"!/� IW i\(�'a. .C�G.a�@�' f�u�l `J► M K : M l.: SI2E: S RE IAL#: U,= �� . q 7.�sc� �'r ,�� ��� TEST DATE: OVERHAUL DATE; INSTAIL DAtE: PREVIOUS OVERHAUL Df1� � � /� ��i -� I Z U(v CHECK VALVE GHECK VALVE' PRES.DIF. ACRt)SS PRES. DIF. WHEN STRAINER � '� NUMBER 1 NUMBER 2 NUMBER 1 CHECK R�UEF OPENS INITIAL LEAK�D LEAKED �NE . T�ST; CLOSED LOSED PSI � PSI CLND INITIAt.TEST PASSED, SUBMIT AS FINAL i�iTi��rEST Fai��D, REPAIR NEEpED DESCRIBE REPAIR; T� � CHECK VAIVE CHECK VAIVE F�R�S.�IF. ACRQSS ' F�R�S. (?IF. WHEN NUMB�R 1 NUMBER 2 NUM6ER 1 CHECK RELIEF OPENS FINAL TEST: CLOSED C OSEO �Si , � _ PSI TEST PERFORMEQ BY: �,ERTIF;C�.?'�f?N NIIM�EF?; • �OMPANY NAME: C P NY R S5: CITY 7�A� '�IP CUDE. T�I�,eHONE NUMBER: METROPOUTAN 73d0 WASHING ON EDEN MN S53d4 952.9d1.7010 MECHANICAI.CONTRACTORS AV�NUE SOUT PRAIRI� 08/3112010 09:02 9529143273 MMC PAGE 63 ANNUAL TESTING OF RPZ VALVES JOB ADQRE�S: �TY: TS ATE: IP 0 : 2sao Sh� wo�. R� ���-w+' J'� N s.�'�.� f OWNERIOCCUPANT; B I OING N ME: D�SCRIPTION OF WORK: ANNUAL � , s dN/y9T'�L INSTALL ALTER REPAIR REPLACE O RHAUL ( b�yN CONTACT PERSON: TELEPHONE NUM6�R: ��;s �ro l� q�2 � 71 q �7.� Y RV • DEVICE IOCATION: FLOOR#: ROpM#: � �T►�lsje..� MAKE; MODEL; S��E: S RE IAL#: �4(�e�� �'i 7—�.>X� ��' `� 737�I I S D 7 : OVERHAUL DAjE: INSTALL OATE: PREVIOUS OVERHAUL DATE: .5 Zf� ��e7 '-1" ,�j" ��� ._ 08 CHECK VA�VE CHECK VAIV� PRES.DIF, ACRASS PRES. DIF. WHEN STRAINER J� NUMBER 1 NUMBER Z NUMB�R 1 CH�CK RELIEF OPENS INI7IAL LEAKED LEAKED NONE TEST' CLOSED C�LOSED .�p PSI �'� PSI CLND INITIAL TEST PASSED SUBMIT A� FINAL J INITIHL TEST FAILED, REPAIR NEEDED D�SCRIBE REPAIR: � CHECK VALVE CFiECK VA�.VE PRES.D)F. ACROSS i�RES. DIF. WHEN NUM6ER 1 NUMBER 2 NUMBER 1 CHECK RELI�F OPENS FINAI. TES7: CLOSED CLOSEO F�SI �^ PSI TEST PERFORMEO 6Y; • RTIFICAT!�� ' �'I;hABF ft• �,._ h---•---.._. COMPANY NAME: CO P R SS: CITY �S7A� ZIP CUDE. TELEPHONE N�MBER: METROPOLITAN 7340 WASHIN(�TON EDEN MN 553d4 952.941.7010 MECHANICAL CONTRACTORS AVENUE SOU�H PRAIRI� 68/31/2610 99:02 9529143273 MMC PAGE 04 ANNUAL,TESTING OF RPZ VALVES JOB ADDRESS: �ITY; STATE: 21p CODE: Z�oo St,,ad wo�o� � ����c�� MN s�'.�/ QWNER/OCCUPANT: BIIILDING NAME: OESCRIPTION OF WORK: ANNUAL 1 �r ��T � INSTALL ALTER REPAIR REPLACE OVERH l ,. '��e.5 t�s S�c�;f CONTACT PERSON' TELEPHONE lVUMBER: �,1.,r Ls �ro� y,�'� �{ 71 9 77,.3 SYSTEM SERVED: I CCATIQN: FLOOR#: O� OM#: �-�4`Y Z.�`cor� � `QC.'�^Zvuc,a ►`�oi'�- �,.�r ��r�7 MAKE; MODEL: SIZE: S RI #: l�-� ?.��5� `�'�J c( Z'` 2�''-� �'ls TEST DATE: QVERHAUL DATE: INSTAI,I DATE; PR I S \/ RH AT : � ZD !D � Zr 6� CHECK VALVE CH�CK VALVE PR�S.DIF. ACROSS PRES. DIF. WHEN STRAINER r1 .� . NUMBER 1 NUMBER 2 NUM@ER 1 CH�CK RELIEF OPENS G INITIAL LEAKEO LEAKED `! , (� ONE TEST: CLOSED CIaS�D (�•T PSI J� �`�' PSI CLND INITIA�. TEST PASSED, SUBMIT AS FINAL 1N�TI:�I,T�ST FAILEp, REPAIR NEEDED DE�CRIBE REPAIR: ������� � ' CHECK VALVE CHECK VALVE f�RES.DIF. ACRQSS PRES. DIF. WHEN NUMBER 1 NUMB R 2 tJUMBER 1 CH�CK RELIEF OPE.NS FINAL T�ST: CLOSED CIOSE� f'S;^�� PSI TEST PERFORMED BY: C�FR7IFICAT'^N I�!I.IMB�k' v � CQMPANY NAME: MP NY SS: CITY S•fAl E• 21P CUDE. TELEPHONE NUMBER: METROPOLfTAN 7340 WASHI GT�N EOEN MN S53a4 952.941,7010 MECHqNICAL COHITRACTORS AVENUE SO Tk PRAIRIE -�--�� ,IUN, 1. 2009 7; 24AM LBP, MECHANICaL Z��� �'���ad A� w • IVO, 112 P� ��5 S ERVI C E � 315 Royalstan Avenue 7e1;612-333-1515 Minneapolis,MN Fax:6�2•333-6122 C 0 N STRU CTI 0 N 55405-1535 Ibpmechanical,�om MECHANICA6,INC• F A C S I M I L E T R A N S M I T T A L ' Date: �l �' �' , To: � Company. �– �°'''� � —,- , � F� � Z.- ZY9 _ �6t � Tel: Copy; File From: �'`�0� project: �� � Subjeck Z� � Qty Pages Date Description Attached: � ,� C t D Remarks; These are transnidted as cheCked below: O FOR APPROVAL 0 APPROVED AS SUBAART�D O RESUBAAIT� COP�ES f�FOR YOUR USE O APPROV�D AS NOTED O FOR DISTRIBUTION 0 AS REQUESTED � FOR CORRECTIONS Q REVIEYV AND COMMEM' D FOR PRICING � RETURN� COPIES G • Comments: � Should you have any q 'o I�s, please contact me at 612 333 1515. Signed: An Equa�Opportunity EmployeNContracto� i � ----JUN. 1, 2009- 7; 24ANr�LBP, MECHANICmL N0, 772 P, 2/5 y3� 70 ' � CITY OF MINNEAPOLIS,R�GUI.ATORY SERVICEB � INSP�CT10N8 DM$ION ' ' 260 Souml 410 Straot^Roqn 300 ; Min�apol'�,MN 5W15-1s16 I ' �yr rw,ci.min a o' S I I B��KFL01�V PR�V�NTOR (RPZ) TES? REPORT �roe�aao�ss: �s'a o s`1�v y a�o� �a�p ow�woccu �a�.��e.� � caKrncr P��, _ � _� PANT/CONTACP PERSOI�k D�VIC�LOCA170N: D� �- �'� �1-. �'� SEfiV6S WHATSYSTQII. . � Mov� . $Q sr�: a n sEwa.�: -7 iNsrnu oa�(a�N�►�AYn�A�f° ovERf+nu�.a►�(MOKnua►r+Y�x '�sT a►1'�I�oNT�Ar�): (oo NOT pur n�rruR�oA7��N Tx�s 6ox� ,S� g s y ° �!'t CHECk VALVE R�e1JEF �CHECK VAW� PS � �f63T BEFORE REP/uR$ 3•e� �.Ir �rp� iIr � ��S� . Fl�a.�r g,a ��s 8�.� .�. � G� Gs,v pESCRIBE REPAIR IF ANY(IF TIiIS IS A NEw(N�ALI.KIION ANp REPWC6S AN�XIgTING DEVICE,INDICATE 1HE SERIAL NUMBER oF TM��nce�)� P TEST DONE RY(PLEASE PRINT FIRST&LAST NANff1� CERTIFIG1T10N NUI�ABER: �� i ' ��ga �� S L. h/ Ci MpLS GO R LJCENSE�t COYPANY NAM�: COMPANY ADpRESS: c�`S� lQ D� ��� � C ANY PHONE� �o�'-�3�^ �!� C�'IY• �P sTA7�: LP: CON'rACT P OWPNONE� G G N ATTACH TNIS COAAPLEi'ED TEST REPCRT 1'�PLUMBIN�aA�FITT�NGIRPZ PERMIT APPUCATION AWD gUgMIT WITH FEE 7�sorzoo7 � i -, �JUN. 1. 2009r 7: 24AM'�LBP. MECHANICAL N0. 772 P, 3/5 � Yao7d ' GTY OF MINNEAPOLJS���vuro�r sERvicEs i i (NSPECT'IONS DiVIS10N Z�p$OUd'1 da Stf9��ROORI 30� i MIml9apclis,MN 5541�1916 i � �..wi�nSene9ll�II n us/mdr BACKFLOW PREV�NTOR (RPZ) �'EST REPORT �oB�o�: s'o �a�rco�rArr P�s�: � coNrNcr�:6/a—�J�1—�z7 �ooR� Ll, �� DEVIC�LOCATION: SERVES WHAT SYSTEM� � ' • nMl�: • Mooa.�: 7 s�: '� � sER�� �a �d g� • MSTA�L�ar�(�oNTH►oaYnr�►Rfi OvEwlAu�.DA�p�W�►Ynr�� �s�'un��oN�n��Y�AR1. (p0 NOT PUT A FUTUR�DAT�IN THI&60X) � oZ c! o � ur �3 S' �ii CHECK VAI.VE REUEF #,Z CNEqC VAW� PS FF s �B�«��a� r0,o e�so �a,o a•� c�s� . fl�T�si' /�,p �%G D l ,d �• � G� ��D. DESCRIBE R�PAIR 1F ANII AF THIS IS A Nk�AI INSTALLATION AND REPLA��S AN��NG OEVICE+IN��TE TME SERIAL NlIMOER OF TME DEVICE REYOVE�1� . T6ST DONE BY(PLEASE PR1NT FIK57&LJ1ST NANE).I CERTIFlCATION NUMBER: /�r c%f �.9�`��.� ' 0 3, fi COMPANY NAME � � MPW CONTRACTOR UC Ps�: COMPANY ADDREBS' S � COMPANY PH B dk /l � �y: ��L.S • ST TE: zIP: CON7'A P E� �N AT'fACH 7HIS COMPLETED TLST REPORT O PLUMBING/�sASFITTiNGIRPZ pEWNIT APPLICATION AND S�BMIT WITH�EE • ' �/3or2oo7 , i �3,JUN.� 1. 2009 7: 25AM LBP, MECHANICAL N0, 172 P, 4/5 ' CITY OR MINNEAPOLIS,REOULATORY SERVICES INSPECilO1�S DIVl310N � 250 Soulh 4 Slreet-Rcom 300 � Minnaapolis,MN SS�16-1916 . www.ci.minneaoo�is.mn.0 r g�t.��L01�l1 PRF1IrENTOR (RPZ) TEST R�POFtT ���� �sod s/�,�D Y woo oa /� �r owni�woccvPa�rr�c��soN: C������ °ONT�`�a:-�171- 7 3 ��, flE1ACE LOCAT�ON: d t PLOGR�c L� ROOM� s�s wNnT s�rs�a: ��Y d C L 9� � ��; sv.�: s��� I(��1.L DA'1'E(���RI: �V�ul.DAT�(IIAONTFi1DAYlYEA�: '�EST DATE(MONTNIDAYIYEAR$ ' (DO NOT hU'T A FU'R�RE DAl"E IN THIS BOX) s- p � �9 d #L G1EC�K VAW� RF.L�EF �2 CHECK YA4VE PS FP �� �sr s�o��PaRs g; o C�.s B �•o , ��� � Fl��sr ,o B�S 9-o C Gs� IF THIS{S A NEW INSTALUITION M1D REPLACES AN E�OSTING DEWCL,INDICATE Tt1E SERIAL HUMBER DE$CR�BE R�PAIR IF AN1f( pF''7�E DEIACE REMOVED). 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S� �Lt�� DESC��E�AIR I�YF TF�S IS A Nff1N INSTAW.ATION AND REPLACGS AN DQS7ING DEVICE,INDICATE TNE SEWAL I�NJMBER o��c�n a� �P � ! TE�SY DONE BY(PLE/►SE PRINT FIRST&LAST NANIEI: CERTIFlCATION NUMBER: � O .33 7 Q F ' ��k C� � : L � a,F � MPLS CONTRACTOR LICENSE fi co�aMr ao�Ess: � '/ 1.. r� cau�a�rr P e� 6 I� �3 3 -r/s- ciTY: `S $TA • N �P: GLS' COMT CT P �� G�'v� ATTACH THiS COMPL�TE�TEST REPO TO P4UMBlNG/OASFlTTIN6JRPZ P�iz1111T APPUCA�ION AND SUBMIT WITH FEE 7rsa2oo7 • � MAY. Z7. 2008 7: 36AM LBP, MECHANICAL N0. 065 P. 2 GIiY OF MINNEAPOLIS,REGULATORY SERVICES � � INSpEC710NS DIVISI�N � RSD South 4°"Straot—Robm 300 � Mitlp6epOlis,MN 55415-18'IB � www.ci.etinneaoW is.mn.usbndr BACKFLOW PREVIENTOR (RPZ� T�ST REPORT �oB�oo�ss: �tS'o �u�oc� OWNER/OCCUPAN77CONTACT PERSON: CONTACT PNONE: - a- DEVICE LOCATION: FLOOR ik h ROOM ie SERVES YYHAT S'ff97ElIA: , •� n�a�: � ' ' Moo�� �7 L., s�: � sewa.�e: �a INSTALL DATE(MONTHIDAY/YEAI�: OVERHAUI.DA1E(NONTWDAY11f�AR� '(�.gT pipAj'E(�yppy�p�; (DO I�T PUT A FIlTURE DATE IN THIS BOX' s" a �' �3 b �t EHECK VAI.V� Ii�LIEF !!2 CHECK YALYE PSUDI p9 F -���a��A�� � �LS.� 7� ,a ��s � f'""`� 7a ec -7-� c�s,D DESCRIBE R�PAIR IF ANY p�7HIS IS A NEYIf INSTALLATInN AND R�PLACES AN EXISTING DEVIC�INDICATE THE SEWAt NUM��RR oF ni�v��ovEu�: �� , TEST DONE B1r(PLFJISE PRINT FlRST 8�LAS7 NAIME}: ' CERTIFlC,ATIOIY NUM9�R: /��G� �� �' �r,?�c3� con�a�nr N : t�P � � � �i � ' n�i.s conrrw►cso�ucE�se� COMPANY Al�ORF.S.S: tS^ �0 �`G� c�i' O � COIY�ANY FMON@#: � 'r,3,� - CfTY: �L�S STA`�E: ZIP: A PERSOI�IPHON�: p77ACH THIS COMPL�T�D TE8T REPORT TO iPLUINeIwc,�c,r►sFn�TiN6rnPa P6RN11T qPpLIC�►TION AND SU�MIT WITH fEE 7�0/2�07 MAY. 27. 2008 7: 36AM LBP. MECHANICAL � N0, 065 P. 3 , I �17Y pF MINNEAPOUS,R�GUI.AT�RY S�RVICES � tNSpECT10NS DIVISION ; 250 South 4u'Street-Raom 3� iMi�neapolis,MN 55415-1316 www�d.minneaoolis.mn.ush�tdr BACKFLOW PREV�NTOR (RPZ) `TEST REPORT �os n�oR�ss: � 6 . bWNER/bCCUPMRlCOM'ACT PER�ON:� � CONTACT PHfJN�: �� DEVICE LOCATION: � � " F�OOR� ROOM� SERVES YVH/1TSYST'EIIM: ' ,Q .�� ,�: Moo��; 96 � �: � �, sEwa.�: � INSTALL DATE(MONTFUDAYlYFAfi�; OVERHAUI.DA?E(MONTHIDAYlYFAR): T�ST DATE(MONTFUpAY/YEAR): (p0 NOT p A FUTURE OATE W THI�BO� � �� o � � � �1 CHECK VALVE REIJ�F �2 CHECK VALYE PSUD F ' 7�ST BEFORE REPAIRS • �INALTEST �� Gt�.�'D ? 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MECHANICAL N0. 059 P, 3/3 r " oP�w►troNs���utAro�v se�nc�s INSPEC710NS DMSION 2so south 4�strs�t—Room aoo Minneapofi�,MN 5541�-1316 wwW.ci.rr�inneapolk.mn.us/tnspections � BACKFLOW PREV�NTOR (RPZ) TEST REP�RT JO�AdDRESS: pyypER►p�xUp�'W'17COWTACT pERSON: CONTACY PHONE: GEVICE LOCATION: FI.00R� ROOM�Ik SERV6S WHA7 SYSTEM: �'�w�- v MAKE: MODEL�: L SI� ll,Z S�RIAI.#: f INSTALL DATE(MONTFUDAY/YEAI��: OVERHAU4 DA7E(MONTFUDAYl1fEAR): T6ST DATE(MONTWpAY/YEAW: �ltinS � #ti CHECK YALVE R�UEF �CHECK VAL.VE Ps�m psiroiF TEST B�Oit�REPAIRS FINALTEST $.l l(SGc�p � , .�. 3.�� � DBSCRI�E R�PAIR IF ANY: , T�ST DON�BY(PLEASE PRINT FlRST 8 LAST NAM�: CER7IFlCATION NUMBER: /'z� � CpMpANlf NqME; CO "fRACTOR L(C6NSE#: COIYIPANV ADDR6SS: �/� '�J/'w� '` ��P 0 �z��`� anr: 3TATE:/�'� 7JP�Y� CONTACT PERSOWIPH�W�: ATTACH COMPLETED TEST R�POR7 TO PLUMBINQJGASFITTIN6/RPZ PERMIT APPUCATION AND SUBMIT Wil'H FEE • ,i APR, 12, 2005 11 : 54AM LBP, MECHANICAL N0. 059 P. 2/3 , oP�r�anonrs s��uu►roaY seRv�c�s �NSPECTIONS DMSIDN �S°uth 4'"8tt'eet—Room 900 Mlnt�pol'�s,MN 55416-9316 www a.minn�apolis.mRus�nspeapor�s BACKFLQW PR�V�NTOR (RPZ) TEST REPORT dOB ADDRESS: � � OWNER/OCCUPANTlCON'TACT PERSON: CONTACT p�IpNE: DEVIC�LOCATION: • FLOOR� ROOM i0: SERViS WHAT SYSTEM: MAK�: MOD�L� SIZE•; �SERIAI.�l:,.,j INSTALL DAT�(AAONTHIDAY/YEAR�: OV�RHAUI.DATE(MONTH/DAY�: 7'E3T CiAT�(MONTWpQYLYEAR): � . `� '��oS �'1 CHECK VAIWE RLLIEF �'2 CHECK VAI.VE PSUDI�F PSUDIRF TEST BEFORE FtEpp1RS FlWA4 7EST $�i�G�LSD $`.1���C� � ��scwsE�aa�F n�nr: 7EST DONE BY(PLEASE PR�NT FlR3T�LAST NAME�; c�1l�canoN Nu1�B�: i S •O� COMP NAM@: �t.c.��.r�. �� G coNrw►cTOR uc�sE� COMP NY ADDftES,S: � S�d�J' �CJ COMPAN1f pHONE�M: �/P-e�aS o�/� CRY: �S STA'fErl`� aP:�� CONTACT PERSOIWPHONf�ik � ATTACH COMALETED TEST REppRT TO PLUMBING/OASFITTINGJRRPZ pERMiT ApPUCATION AND SUBMIT WITH FEE r - MAY. 15. 2006 12: 31PM LBP. 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MECHANICAL N0, 811 P. 3 � v �v� J.� . , ' OP�RATIONS&R�CUUITORY SERVICES INSP�CTIONS DMSION 250 Soud14'�'Street—Roan 300 Minnsepolis.MN 85475-�1318 vrww.Ci.minn�polis.mR�nspections B,ACKFLOW PREVENTOR �RPZ) TEST �REPORT � .lOB ADDRFSS: • . p�yyp��i/pCt�JppN'fK;ONTACT PERS N: � CONTAC7'PHONE: • W' DEVICE LOCATION: ,(f�,� Q�/� C%l4�/� ' FLOOR� p��. ROOM#: SEf2V6S WFIaT SYSTEM� � . . MAKE: �f C���"'�" MOD�L.� �I 7.✓��Ji � SIZE' .7�, � SEW/1L� c� 'e3 .��}. INSTALL DATE(M�ONTWDAY/YEAR1c OVERHAUL DATE(YON7FUDAYlYEAR►: 7FST DA1'B(MONTWDAYIYEAR�: � � /�- d,&'t'. .. :,;;. � � #�cHEc�c vy►I�vE � �s cHecK vA�v� . °•. PSIIDIF� PSUDIFF TEST BEFORL R�PAIRS FlNAL TESI' ��Q `/� �d,lJ �.� � p�,scw�e�aR�F a��r: TEST DONB BY(PLEAS�PRIN7 FlRST S L.AST NAM�I� C�11F1'�ATION NUM�ER: 3 � G /�' � 6 NPAN1f NAM�: � L—• CONTRACTOR LICENSE#: co��wYAoo .� coMPANY�oNEi�' �'/�-' 333 � C�• STATE: aP• CONTACT PERSOWPNONE�k A7TACH COMPLEfED T�ST REPORT TO PLI�AABING/GASFl7'f'ING/RPZ PERMIT APPLICATION AND SUBMR VYITH F�� -� MAY, 15. 2006. 12; 37PM � ��LBP. MECHANICAL N0, 811 P, 4 �--.ti.t��'`e� OPERA7'IONS b REGULA70RY SERV�CES 1NSp�CTIONS dIVIS10N 250 5oudt 4'"Street—Room 300 Minnaapolis.MN 66415f1316 www.ci.minnaapoi'is.mRusfi�spectloes BACKFLOW I'REVENT4R (RPZ) TEST REP��RT �os�wo�ss: �5 ab � OYYNER�OOCIJPANT/CONTACT PERSGN: • CONTACT PHONE: • FLOOR� ROOM�: DEIACE LOCATION: ?,�, aD� SERVES WHA7 SYSTEM: ��� W��E��" � `' �""�' ,�, � ` - �ooE��: �� �'X�— �. I �' 5��.� 7a �� 9'� INSTAI.L DATE LMIONTi�11DAYlYEAR): OVERHAUL�ATE(NON'fk�IIDAY/YEAf'i): T6ST DATE(YON7EUDAYIYEAR): �' N 6.6 � �cH�ic vp�.vE �u� �t c�ac v�vE PSUDI ��� �sY s�o��aRs �p, � �@� IP -Ft a. � G�LS� � F1(dpl.T�ST . � � AIR IF ANY. • � DESCRIBE R� 'R8T DONE BY(PLFJWE PRINT FIRST 8 LAST NAA�E1- CEFYfIWCATION NiJMBER: L�- �l �rc� �;�s f/�- D�y.3 T' /7" CO PAN1f N E: ' �p t COM1iACTOR UCENSE� COMPANY ONE� �� 3 3 I•�J COMP ADDRE3S' �J�S� cirr: srA • aP: .�,� coHrAcr�sowPHON� ATrACH COMPI.ETED TEST REFORT TO PLWMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT Wn'H FEE � MAY. 15. 2006�.,12:37P�M�� LBP. MECHANICAL N0, 811 P, 5 OI�RATIONS ae REGULATORY SERVICES INSPFCT10N3 DMSION 25o south 4'"Street--Room 30� Minnaapblls,MN 5541511316 � www ci.minn�polls.mauslinspeWons , . BACKFLOW PREVENTOR (i2PZ) TEST REP�RT JOB ADDRESS: ��'OO OWNERIiOCCUPANT/CONTACTPERSON: � • NTACTPHONE: DEVICE LOCATION: �� FLOOR� ��,,,e ROOIYI� SERVES WHAT SYSTEM: � � �`D�� �`-�� MAKE: �,JA„�`,S' MOpEL�: �O � s�� �� SERIA��:� /S� INSTALL DAYE(AIONTWDAYIYEAR� OVERHAUL qATE(MONTH►DAYIYFAR): TEST D/►7'E(MONTHNAYIYEAR): 5` !/ Q�' ih CHEdC VIALH� RF.�IEF �R'1 CHECK VAI.VE p��p� PSUDIFR �sT B�o��aRs �a.� �L,t,� �o� � !• �L�S,O FINAL YEST . pESCRIBE REPAIR IF ANY: . TEgT pONE 61r(PLEASE PR1NT FlRST 8 LAST NAME)� CEKpFICA710N NUIMHER� (.Z� !� � /��� /1- �'9— 0.��13 T COMPANY NAME: CON7'RACTOR UCENSE� COMPANY ADDRESS: / N � COMP PHON�� Z :3� SIS C�: �A� ap: CCNTAG?P�RSOI�uPHONF�k ATTACH COMPLETED 7'EST REPORT YO PUNIABINGIGASFITTINGIRPZ PERMIT APPLJCATION AND SUBMIT WITH�EE