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HomeMy WebLinkAboutbackflow preventer tests � r�EDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT AND � . � TESTABLE DOUBLE CHECKS 3er' � Name: C1'� d''F 4�N � ' Contact Person/Tole /�•/j� . addr�ss: sH���•(!£ O , �pt,�J�J 9� ��-�?70T 3770 O�¢o�MM c��y:�1i��.QE state: �y�� zlp: r,�3a3 . �evlce �ocation�� �`. M� Serve.what system: ��� ''j��� Q� F�w account Number: �� Serlal Number: eis"J3qp rype. Make: WATTS Model: cT� �°� nstt�ll Dale: �,ir Gap Inst�llation Dete ' Rebuild D�te: 7est Date: � ��/ /o G Annual Chock Valve#1 •� Chock Valve#2 pifferenti&I Pre�sure Reliof Valve Report ' . Pressure �_ .°� Pressure � Opened at a.9 usid reduced pressure. . Did not open .�_ Cleaned `�, Cleaned Cleanod ��, Replsced Replacod Ro(�laced R ,"__ Di�c Olsc � _, 5prin S rin Disc, Upper P �, Guld� Guida Disc, Lowar q � Spring `_ Pin Rotainer Pln Ratainer Olapl�rdpm, Large � �: Hinge Pln Hin9e Pin Lower R :,,., Seat Saat Upper ,..�,� Dlaphragm Diaphr:�gm Diaphragm, Sm�ll �_ Othar,descr(be _.� Other, doscribe LOwot Up�er Seat: lowor . , Upper . Spacer, Lower . .�+ Other, doscribe -� 1 Sign and date Tag the above la cerlified carrect. Signecl � / DateTested:r? l��f L 06 Pested by(p�jnt Name) Lenn Gavic CertiFlcation N umber 0 0 4 4 2'� Corporate Mechanical, Inc 5114 Hillsl�oro Ave N MN License Number 005363PM New Hope, MN 55428 ;763) 533�3070 =ax (763) 533-34G4 � � D00IE00 'd Sl �9l (3f11)9002-81-1f1f REDUCED PRESS�URE BACKFLOW PREVENTER TEST REPORT AND � � TESTABLE DOUBLE CHECKS Gl?� C�' 4QQN D Cont�ct PersonJTele M�� �pwr►1 �iSvZ• �73— 97a/ tddress: �.?.Tp �/:�G/� O . City: oF OQoN O Stat�; �t•/�/ zip: �;3�3 � �evlce Locatlon: ��u� �' � 21�0 FG. M�+� I�M, SgNe what systam: Q��� Wp� ►ccount Number; •• Sorial Number: alg'�a�. .ype' M�ko: WATTS Model: 6Qq . M Z nstt�ll Dato: Air Gap Install�tion Date �oNE " �abuild Date; Tast Date: �l���Q6 Annual �heck Valve�1 •� Check Valve#2 Differential Pressure Relief Valve Report ' Pre�sure g`4 pressure � Opened at a.a psid reduced pressure. Did not open Cleaned CleenecJ Cleanod Replacod Replaced Replacad R �� Oisc �! Disc E Disc, Uppor _, Spring Spring DiMc, Lowor P .�_ Guide Guide � Spring A �_ Pin Rec�iner Pin Retainer Dlaplvagm,Large � :_ Hingo Pln Minyo Pin Lower R �,^ Seat • • Seat Uppor Diaphragm Diaph�agm diaphragm, Small Othar,dasbribe Othor,describe Lower Upper SE:�I: Lower . ' Uppor � , Spacer, t,ower O�her,describo ..�] Sign and date Tafl rhe above Is certlfled correct. Sigrted � DateTested:`7�I_yC�06 I'estod by (Print Name) L�nn Gavi c Certiflc3lion Numb�r 0 0 4 4 2T Corporate Mechanical, Inc MN License Number 005363PM 5114 Hllisboro Ave N New Hope, MN 55426 (763) 533-3070 =ax (763) 533-3464 � DOO/U00 'd Sl �9l (3f11)9002-81-1f1f ' ` 3?7o Sh���..we ,Q I�� Feb 26 07 06: 23a Mar� Borns Ceil#612) 685- (952) 937-9165 P• � REDUCED PRESSUR.E BACICFLOW PRE��'ENTLR TES'1� RLPORT AN� i ESTA$"LE Dt`�UBLE. CI�LC1<S Service Name: ` Cont�ct Persor,iTele w e ^ ` City: ,�,�f'B 1'1 D �tate: ��► _ZiP� _ 3�3 Adcress: �(�! � Device Loc�tior: � ,'�� G�►1�,.]rt +� Serve�.vhat system: ���f�P '�Y U G�'4�� �� Fccount Number. Seri21 Number. � � ,� Type: Make: �viodel: �Q�.._ Size: Install Date: Air Gao Install2�ion Gate Rebuild Date: l � - / — �� Test Date: � ��� �,nrual Check Valve �1 Check V21ve #2 ��ifferential Pressure Ralief'Jaive Report Oper.ed at ��sid r2cuced prsssure. Pressure �� Pressure ��_ . Did �o[•�pen Cleaned Cleaned ��laaned Replaced Replacec ReplaCe� R Disc Disc �isc: UpF•er E Spring vp���9 _ G�isc, Low�r P Guide Guid� S•vrmg : .r=, Pin Re:ai�er ?in Retainer __ �iaphragm, �arr;e I tiinge Pin h�nge Pin ._ Lo�^;er rt Sez: Saat r_)c�per C�iapnragm Ji�phragm ��i�phr�gm, Smail y Other, describ? uthe�,describe _` _�;v�r ���pef . �.,a'. ���riBr Upper SDacer, I.o�•�er vTher, ��scribe �� Sian and date 7ag i he above is certified correct. SiSred ..� �a:�Tes;e�: O � Tes�ed by (Print Name) � � I�,P r� �L�Y_S Ul/� Cerlifica�ion Number(%��� Corporate Mechan.ical, Inc. 51 l4 IIiI[sboro Avenue North �ew-Hope, MI�° �5428 Phone (763)533-30i0 Fax (763)533-.i464 Feb 26 07 0�: 23a Mary Horns Cell#6121 685- (9521 937-9165 P• � REDUCED PRESSURE BACICFLOW PRE��'ENTLR TES'1� RLPORT AN� iESTABLE DOUBLE. CI-ILCKS t ' r�f1.�11 Service Name: �J A 1 a��u�P �� �'�P �.��'sd:�. Contaci Psrsor,iTele -� Adcress: � � �� �.i V� u�as ►1P_ City: ��'O`RO State: L�Y11r?�P� ��1�t� Device Locatior: /"l PZZan ►I�t� Serve �.vhat systerr: ��'�SS �tYe �� Account Number. Ser2f Number: � � '�5 � n,�,p�n 4 Type: Make: viedel:�ll�.o� S�ze: Install D2te: Air Gao Install2iion Date Rebuild Date: �J� Test Da;e: —�� �,nnuai Chec;� Valve �1 Check Valve #2 ��ifferential Pressure R21ief`Jaive Report 3.� osid recuced pressure. Pressure �� Pressure •� Oper.ed at . Did no� open �leaned Cleaned '��2a��ci Replaced Replacec F�eplacec R Disc Disc ��sc; Upper E Spring �pr��9 _ Disc. Lo�ver P Guide Guid� S;.'nng /=. Pin Retair.er ?in Reiainer �iaphragrl, I_�rg� I Hinge Pin h`n5e Pin ._ Lo�^:cr : � Sez: S�at �_�cper ; C�iapnraom Ji�ptiragm ��i�phragm, Smail y Other, descrite Gihe:,describe __ _�,,��� _ U�per �eo,: L����er UPper 5aacer, I_o�•�er Gther, desc�ibe L_�!/ Sign and date 7ag i he above is certified correct. SiSred � . Ct,,GDv�- �a:�Tes;e�: O 'a l�—Q� Tes[ed by {Print Name) �/��r� �Q i�,S n�. Certif;ca�ion NumberQ7 7a�� Corporate Mechan.ical, Inc. 5] ]4 IIillsboro Avenue North �etiv Hope, NfN �5428 Phone (763)533-3070 Fax (763)533-3464 Feb 26 07 06: 23a Mar� Borns Cell#6121 685- f9521 937-9165 P• � REDUCED PRESSUR.E BACI�FLOW PREVENT�R TES'1� RI:;PORT AN� i ESTAB"LE DOC?BLE. CHLC1<S I\1/�`1f/.t Y'Y� ��� �° ���� Contaci Persor,iTele '_` �-�-� rd )1�--- Service Name: � Adcress: � � d �� V�s'�^ �U�° City: �✓61'LD State: �?�P��y� Device Locatior: �Z 7/.t Yt�YI e Serve�.v ha t systerr: Account Number: ' Seri2( Number. 55 r� �ype. Make: I/II d �tedei:C� S�ze: install Dace: Air Gao Install2'tion C�ate ftebuild Date: Q� Test t7a;e: U ���{-�/ Annual Chec�`✓alve �1 Check Vaive .#2 ��ifferential Pressure Rzlief`Jaive Report Oper.ed at V �sid recuced pressure. Pressure �.a Pressure � 1 • ' Did not open Cleaned Cleaned ��1e2��:ci Replaced R�placec Replacec R Disc Disc �isc, Upper E Spring �pr��9 _ C�isc. Low�r P Guide Guide S•,:r�n9 : �`, Pin Re:ai�.er _ 'in Reiainer �iaphragm, �ar,r,e I Hinge Pin h:nge Pin Lo�^;cr rt Sea; Seat �_Ic,per Ciapnraom Jisphragm Dizphr�gm, Smail y Other, descri�A viher,describe _` : ��,v�r _ U.�per �ed': . ���r�gr �-�pPer 5oacer, t_o�ver •�iher, �escribe ��Sign and date 7ag The above is certified correct. SiSned � d`- �a;�Tes;e�:�' p��-Q� Tes�ed by (Print Name) �l�j�-�- L�O11r5 C7Y1 _ Certif;ca�ion Number��T Corporate Mechanical, Inc. 5114 I�il[sboro Avenue North ��ew�Hope, MT �5428 Phone (763)533-3070 Fax (7G3)533-�464 Dolder Pl�umbing & Heating, LLC. �,,, 7760 County Road #26 Maple Plain, MN 55359 � -% Phone: 763-479-1942 Email: robdolder@aol.com BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: `��O � �� / OWNER/OCCUPANT/CONTACT PERSON: /�e � � CONTACT PHONE: DEVICE LOCATION:� C /�� FLOOR#: � ROOM#: ` SERVES WHAT SYSTEM: � �// �� `Q� /� MAKE: � MODEL#: o� SIZE: �� SERIAL#�: Z����D INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONfiH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) z-S- zo�� #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF PSI/DIFF TEST BEFORE REPAIRS FINAL TEST � !� , � � / DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): TEST DONE LEASE PRINT FI 8�LAST NAME): • � J CERTIFICATION NUMBER: __ ._ __ . _ ___ __ _ _ _ STATE OF MINNESOTA BAC;{FLOW ftPZ TESTER UNLIMITED Te+EsT ,�!� .. �,:: License# 061486-BF �� ... Expiration �)ate �. Orii inal Issued Date 04/16/1998 '�,"" � `' J ' ;�� �•iaid ROBERT W DOLDER 404 GREEN AVENUE SOUTHEAST WATERTOWN, MN 55388 \` Dolder Plumbing & Heating, LLC. !, 7760 County Road #26 Maple Plain, MN 55359 �•.. -% Phone: 763-479-1942 Email: robdolder@aol.com BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: z��� . ✓� �-,;� ,s��� �J � l�•� U OWNER/OCCUPANT/CONTACT PERSON: ' , CONTACT PHONE: / C DEVICE LOCATION: ��ZZ���h,� FLOOR#: � ROOM#: ' SERVES WHAT SYSTEM: ��5 ` � G / � /�" / MAKE: /'.) MODEL#: �,y�� SIZE: � SERIAL#: ��f y�, (�� /�� INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MON�'H/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): /�'�'�O� (DO NOT PUT A FUTURE DATE IN THIS BOX) l��"X/Z #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF PSI/DIFF TEST BEFORE REPAIRS FINAL TEST �j � � �j�� � o (/ � DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): TEST DONE BY(PLEASE PRINT FIRST 8 LAST NAME): � CERTIFICATION NUMBER: ___..__ _ __ STATE OF MINNESOTA BAC�{FLOW RPZ TE5TER UNLIMITED �itEsy,�>� '��;:. �, Licc�nse# 061486-BF � -��i. ExF;iration i)ate Oric mal Iss.ied Date 04/16/1998 � �� -.` � �.'�+`�. ROt3ERT W DOLDER 404 GREEN AVENUE SOUTHEAST WATERTOWN, MN 55388 Dolder Plumbing & Heating, LLC. �„ 7760 County Road #26 Maple Plain, MN 55359 � -�% Phone: 763-47,9-1942 Email: robdolder@aol.com BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: �77� � � S �_ OWNER/OCCUPANT/CONTACT PERSON:/,� L��*C. �''CC CONTACT PHONE: GV r% DEVICE LOCATION: �� Z �' FLOOR#: �c�-- ROOM#: SERVES WHAT SYSTEM: O r O,,�R � �G� . MAKE: MODEL#: � SIZE: 3� SERIAL#: 9/���Z ��� if INSTALL DATE(MONTH/DAY/YEAR): OVERHAUL DATE(MONfiH/DAY/YEAR): TEST DATE(MONTH/DAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) /�-�= 20/ /- �a 2 #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF � PSI/DIFF TEST BEFORE REPAIRS FINAL TEST �v ��G�' �� � � DESCRIBE REPAIR IF ANY(IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE,INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): TEST DONE BY(PLEASE PRINT FIRST 8 LAST NAME): CERTIFICATION NUMBER: _ _ _ _ _ _ _. __._.. __ STATE OF MINNESOTA BAC±tFLOW RPZ TESTEYt UNLIMITED �ci�s�,,� :�.,.. _ �..� ;:�,`,.,,...,.,: . License# 061486-BF s; ExE;iration t�ate � Oriyinal Issued Date 04/16/1998 ���.y`��j. ��';� '"L'����ht"� ROk3ERT W DOLDER 404 6REEN AVENUE SOUTHEAST WATERTOWN, MN 55388