11.4.2020
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Development Services Customer Service Center Office Use Only
Application Form
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250 South 4 Street – Room 300
RBA01
A/P LIC #___________________
Minneapolis, MN 55415 – 1316
Office 612-673-3000 or 311/ Fax 612-370-1416
Date: ______________________
TTY 612-673-2157
Amount ____________________
www.minneapolismn.gov/mdr
REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT
COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER
Boplb!Dpvouz!DBQ
491!68ui!Qmbdf!OF
APPLICANT COMPANYNAMECONTRACTOR LICENSE #CONTACT NAME AND PHONENUMBER
ADDRESSCITYSTATEZIPEMAIL
TESTER NAME TESTER CERTIFICATION # PHONE
TEST EQUIPMENT MANUFACTURERTEST EQUIPMENT MODEL#TEST EQUIPMENT SERIAL #TESTING EQUIPMENT CALIBRATION DATE
Mo_______Yr______
TYPE OF WORK (check one)
FEE $.0
FEE $
5
R
Rebuild
elocate RemoveReplace and SN# of Replaced Device
Install Test
_____________
BACKFLOW ASSEMBLY DETAIL INFORMATION
5
Type (check one): Reduce Pressure Principal or Pressure Principal Fire Protection Reduced Pressure Detector Fire Protection
Double Check Valve Double Check Detector Fire Protection Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker
Manufacturer:________________________ Model #____________________ Serial #____________________ Size:____________(inches)
Floor #______ Room #________
System Serviced___________________________ Location in bldg _______________________
5
TEST RESULTS: Pass Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW)
Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) – TEST RESULTS
Pressure Differential
Check Valve #2 Shutoff Valve #2 Check Valve #1
Relief Valve
Closed Tight YesNo Closed Tight YesNo Closed Tight Yes No
Initial
Opened at ______psid
Test
Pressure Drop Across Check Valve #1_______psid
55
5
Final Closed Tight YesNo Closed Tight YesNo Closed Tight Yes No
Opened at ______psid
Test
Pressure Drop Across Check Valve #1_______psid
Double CheckValve or Double Check Detector Fire Protection(DC)–TEST RESULTS
Check Valve #1 Check Valve #2 Shutoff Valve #2
Initial Test
Closed Tight YesNo _____ psid Closed Tight Yes No ______psid Closed Tight Yes No
Final Test
Closed Tight Yes No _____psid Closed Tight Yes No ______psid Closed Tight Yes No
Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) – TEST RESULTS
Air Inlet ValveCheck Valve Shutoff #2
Failed to OpenYesNo Closed Tight Yes
Initial Test
Closed TightYesNo
Pressure Drop Across Check Valve #1______psid
Opened at _______psid
Closed Tight Yes No
Final Test
Opened at _______ psid
Closed Tight YesNo
Pressure Drop Across Check Valve #1______psid
Describe parts and repairs when needed:
I hereby certify the foregoing information provided by me to be correct and that the tested
CERTIFICATION: device isfunctioning in compliance with
State of Minnesota Plumbing Code, Chapter 4714.
2205031
DATE:____________
TESTER’S SIGNATURE
MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO
ACCOUNT# CVV#
ALL MAJOR CREDIT CARDS ACCEPTED
EXP DATE: Mo____Yr___
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