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mechanical. contractors, incil <br />1257 Marschall Road, P.O. Box 237 Shakopee, MW 55379 <br />Phdne:' 952!445-5100 Fax: 9521445-5119 <br />NAid1E OF BUIL , O, ODUNERIOCCUPANTi CONTACT AM€ -AND PFIONE NU"J1BER <br />COMPLETE JOB ADDRESS (INCLUDE Apt•/Onit #) <br />:f.1 '6611 rJ Al, 6 <br />APPLICANT COMPANY NAME <br />CONTRACTOR LICENSE # <br />•CONTACT NAME AND PHONE NUMBER <br />Associated Mechanical Contractors <br />LOSS 22749 <br />,Charge Riechers 9�2-445:5100 <br />ADDRESS <br />PO Box 237 <br />CITY <br />Shakopee <br />CheckValve#1 <br />Check Valve #2 Shutoff Valve #2 Relief Valve <br />STATE <br />Mfg <br />ZIP <br />55379 <br />EMAIL <br />criecbers@associatedmechanical.com <br />TESTER NAME <br />TESTER CERTIFICATION # <br />PHONE <br />Scoff Gieske <br />BF638161 22942 <br />952-445-5100 <br />TEST EQUIPMENT MANUFACTURERTEST <br />EQUIPMENT MODEL # <br />TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE <br />Wilkins <br />845 -TK <br />Opened at -'psid <br />09070525 <br />I <br />Mo 12 yr <br />e <br />____Install _ Relocate Remove Replace and SN# of Replaced Device ,_ Rebuild /� Test <br />. • .. '�i�C�C��C'iVil'A�5�11�E�Y �E"�'�±(i!r`(i!).E�64i�igi'IDial ' ., <br />Type (check one): jCReduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection <br />®Double CheckVValvq _Double Check Detector Fire Protection —Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker <br />Manufacturer:_/fI;�T_ Model #, �� �� serial # 3S /C� size: 3%� (inches). <br />T <br />system Serviced Location in bldg Az'e6 A-- Floor#�_ Room # <br />TEST'°�$�T'511:T'Se ass. fail,C.LTrEPC'5(`fltLiii`YPSGIQh! lf3l�VI%), <br />(�ed1BCe'{� PrSS@AP.�i9liClpal Or�iedtlC�t� PCeS5L1Y'4: p8i@G$tlY 0Ir� �f0�2C�IOii �RP, fESf REl1(:T <br />Pressure Differential <br />CheckValve#1 <br />Check Valve #2 Shutoff Valve #2 Relief Valve <br />Initial <br />Closed Tight Yes _--_No <br />Closed Tigh� Yes —No <br />Closed Tight Yes _No <br />Opened at ��psid <br />Test <br />Pressure Drop/Across check Valve #1 psid <br />Final <br />Closed Tight —Yes—No <br />Closed Tight _Yes —No <br />Closed Tight —Yes—No <br />Opened at -'psid <br />Test <br />Pressure Drop Across check valve m psid <br />Double Check Valve or Double Check Detector Fire Protectiol (DC)—TEST RESULTS <br />Check Valve #9 <br />Check Valve #2 <br />Shutoff Valve #2 <br />Initial Test <br />Closed Tight _Yes _No psid <br />Closed Tight _ Yes _, No psid <br />Closed Tight ,_.,,Yes _No <br />Final Test <br />Closed Tight _Yes _No psid <br />Closed Tight — Yes —No psid <br />Closed Tight _Yes—No <br />Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) —TEST RESULTS <br />Air Inlet Waive Check Valve Shutoff #2 <br />Initial Test Failed to Open _Yes _.No Closed Tight _,_,Yes _No <br />Check Valve #1 psid <br />Closed Tight _Yes _No <br />Opened at psid Pressure Drop Across <br />Closed Tight _Yes No <br />Final Test Opened at psid Pressure Drop Across Check Valve #1 psid <br />Closed Tight _Yes , No <br />Describe parts and repairs when needed: <br />CERTIFICATION. I hereby certify the foregoing information provided by me to be correct an at '� -dice' functioning in compliance with <br />State of Minnesota Plumbing Code, Chapter 4714, <br />TFSTER'S SIGNAT TEST DATE: <br />1� <br />