HomeMy WebLinkAboutReport on Backflow Prevention Device #2 RYAN COMPANIES Suite
INC. RYAN®
50 South Tenth Street,Sute 300
WWW.RYANCOMPANIES.COM
Minneapolis,MN 55403-2012
612-492-4000 tel BVILDING LASTING RELATIONSHIPS
612-492-3000 fax
November 3, 2010 Nollv E®
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Ryan Companies US, Inc ?0
50 South Tenth Street C/7),OP 10
Suite 300 ORONO
Minneapolis, MN 55403
City of Orono
Attention: Building Inspector
P.O. Box 66
Crystal Bay, MN 55323
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
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,
Nicole Gieske
Ryan Companies US, Inc.
Building Services Coordinator
Nicole.GieskegLZyanCompanies.com
Office: 612-492-4693
Fax: 612-492-3693
AZ LICENSE ROC195813 CLASS B-01 COM.ROC212330 CLASS B-01 RES.,CA LICENSE 842487,FL LICENSE CGC1506553,CGCI511473,CGC1506271,CHICAGO,IL LICENSE GC04631A,OR LICENSE 161162,WA LICENSE RYANCV1966KK
NEWYORK STATE ARTMENT OF HEALTH Report on Test and Maintenance
Bureau of PubliccWater Water Supply Protection
Flanigan Square,547 River Street,Room 400
Troy,New York 12180-2216 of Backflow Prevention Device
Please use a separate form for each device. For the year
Initial test- Complete entire form
Annual test-Complete Part A only
Public Water Supply Account No. County Block Lot
Facility Name
Location of Device
J i1.1Q
Addressr� , V�JkQ -
Street City Zip
Device foanufaqturer Type =RPZ Model Size(in inches) Serial Number
Information �
,� Q'c" , t( l / �lo3G
Check Valve No.1 Check Valve No.2 Differential Pressure Relief Line Pressure psi
Valve
Test Leaked Leaked Opened at psid Date I—�—
before Closed tight Closed tight
repair Pressure drop drop across first check valve M D Y
psid
Describe Repaired by
repairs and Name
materials
used
Lic#
Date repaired:: �l l
LTJ [I__J
M D Y
Final test Closed tight Closed tight FQ, Opened at�Zpsid Date
K- 4-� 71T] ELI
Pressure dro a ross first M D Y
check valve sid
Water Meter Number Meter Reading Type of Service:(check one)
❑Domestic ❑Fire h-< Other_
Remarks(Describe deficiencies:bypasses,outlets before the device,connections between the device and point of entry,missing or inadequate airgaps,etc.)
Ce A cation:This device 1:1 meets, 0 does NOT meet,the requirements of an a able con"Ifime evice at the time of testing
I hereby th f regoing data to be cw /l 7
1� t
Name Certified Tester No. ure Expiration Date
Property owner's(or owner's agent)certification that test was performed:
Print Name Title Signature Telephone
rrebyCertification that installation is in accordance with the approved plans. (To be completed by the design engineer or architect or water
supplier.)
ify 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
City State Zip
Signature
NOTE:Send one completed copy to the designated health department representative and one copy to the water supplier within 30 days of the testing device.
Notify owner and water supplier immediately if device fails test and repairs cannot immediately be made. DOH-1013(9/91)