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Home My WebLink AboutConfirmation of a Backflow Prevention Test RYAN COMPANIES Suite INC. RYAN° SO South Tenth Street,Sute 300 VCVAVA.I:LVAt 11\It'VAI��.0 11\I Minneapolis,MN 5S403-2012 612-492-4000 tel BUILDING LASTING RELATIONSHIPS 612-492-3000 fax January 4, 2012 Ryan Companies US, Inc 50 South Tenth Street Suite 300 Minneapolis, MN 55403 Receive,)City of Orono Attention: Building Inspector `�� -- 2012 �I P.O. Box 66 TY OF Crystal Bay, MN 55323 OR�IvO Dear Building Inspector; This is to confirm that a Backflow Prevention test was completed within your city. The building address that the test was performed was located at: Crystal Bay Business Center 2725 Wayzata Blvd Orono, MN Enclosed is a copy of the report and test results from our certified engineer. The Department of Labor and Industry requires our company to inform the city that this test was complete. If you should have any questions, please call me or email me. Sincerely, u�lLd Michelle Schuett Ryan Companies US, Inc. Building Services Coordinator Michelle.Schuett@RyanCompanies.com Office: 612-492-4254 Fax: 612-492-3254 AZ LICENSE ROC195813 CLASS 8-01 COM.ROC212330 CLASS B-01 RES.,CA LICENSE 842487,FL LICENSE CGCI506S53,CGC1511473,CGC1506271,CHICAGO,IL LICENSE G004631A,OR LICENSE 161162,WA LICENSE RYANCU1966KK Ryan Companies US, Inc 50 South Tenth Street, Suite 300 Minneapolis, MN 55403 612-492-4953 David Mollen Report oil Test and Maintenance of Back ovy Prevention Device Please use a separate form for each device. For the year_ Initial test- Complete entire form Annual test-Complete Par!A only Public Water Supply Account No. Count Y - Blork Lot /FaciliNamLocation of Device ty es I 'f �, Address 11 ��. P �1 -55" � Street City Zip Device Manufactur r Information Type PZ_ M el Si e(in,inches) Serial Number �) L /_ �JCV Y /V Check Valve No.1 Check Valve No.2 Differential Pressure elief Line Pressure (� psi Valve Test Leaked B Leaked 0 Opened atsid Date ht g Closed before Closed tiP I tight O l—1 —� m � 1 repair l J Pressure drop across first check valve psid M D Y Describe repairs and Repaired by materials Name_ _ used Lic# Date repaired. i M D Y Final test Closed tight Closed tight Opened at Date P psid fx Pressure dr oss first D tY[ check valve psid Water Meter Number Meter Reading Type of Service (check one) ❑Domestic ❑ Fire NQ1_ Otherk�� Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc.) C I I tion'This device meets, 11 does NOT /m}�eett,,the requirements of an septa le c t vice at the time of testing �%r hereby �tif✓tp��///for�oing data to be cot /v ✓ L Print Name �'r(/J Z`C /`-- Certified Tesler No. Ignature / /-- Expiratiun Dale Property owner's(or owner's agent)certification that test was performed 1 G tis \/f/�11t �In Pri IName ITiI 1 I i/ I��--�:C"�y�'t �� _'!�_ � SY Signature Telephone Certification that Installation Is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby certify-that this installation is in accordance with the approved plans. — Name Title Date NYS DOH Log# License Number Phone( ) m d y — -- Representing Describe minor installation changes Address State Zip iSini-I?iu re _-_ I Sunt or omoleteG cnnv it, • ,�, r� �i wait-�Jp,o I(`I II`.i..J,u,vi uEvuc rte:= v daof e"IC fa lis Idsi d,u repair§carinoLIrnnledlarely be made. —.— U01-1-1013(9191) Ryan Companies US, Inc 50 South Tenth Street, Suite 300 Minneapolis, MN 55403 612-492-4953 David Mollen Report oil Test and Maintenance of Back ovv Prevention Device Please use a separate form for each device. For the year_ Initial test- Complete entire form Annual test-Complete Parf A only Public Water Supply Account No. County Blork / Lot [� � Location of Device Facility N))am Addres67C4L-11i iI4r`v Ow Street City Zip Device Manufacturer TypeAli PZ Model Size(in inches) Serial Number nformation ` �CV L 3 Check Valve No 1 Check Valve No.2 Differential Pressure Relief Line Pressure Valve psi Test LeakedB Leaked Opened at psid repair Date before I Closed tight Closed tight Pressure drop across first check valve psid M D Y Describe ——'– --- repairs and Repaired by materials Name_ used Lic# Date repaired. M D Y Final lest Closed tight 9 � Closed tight Date Opened G psid � � /��/�� Pressure drop cr s first 'M I p F12 IJ I check valve psid Water Meter Number Meter Reading Type of Service_(check one) Domestic ❑ Fire Other— Remarks(Describe deficiencies.bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc) Certification This device meets, L does NOT meet,the requirements of an ac ptab e con inme t ice at the time of testing I her b rtify f gin data to be correct �t Print Name lb- 7 Certified Td Tees�tter✓✓✓,No_. Signature Expiration Dale / Property o finer' (or owner's agent)certification that test was performed: iA4oVQ 0�d Pri Name Title Si nature Telephone Certification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water supplier.) I hereby c rtify that this installation is in accordance with the approved plans. — — Name Title Date NYS DOH Loy M License Number Phone( ) m d y Representing Describe minor installation changes Address I I Ciy _ State Zip i Sid rl'n iU fr_ � I •,l,_1 c.Sena on comoietetl-, ,a n _ - ..;, •.-c.;d: ra,a, -rF,,�, ..o�days o:%r—ting devic�— ---- dp�; and M crc"oup��IC` II'.....J�o..;�� evi�c iaie�2a�a,,U Iepalrs cannot rr lrrledlaten,be made. L)011-1013(91191)