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HomeMy WebLinkAboutRPZ Tests 1.15.16 • Cross Connection Control Performance Test OWNER INFORMATION Please print clearly in ballpoint pen. Owner Name - Street Address Kwik Trip, Inc 1626 Oak Street/PO Box 2107 City State Zip Code Owner's Contact Person Telephone Number LaCrosse WI 54602 Stacey (608)781-8958 FACILITY-INFORMATION ' • • • • Facility Name Street Address Kwik Trip, Inc Store#251 16751 Fish Lake Rd SE City Zip Code County Prior Lake 55372 Assembly Location Assembly is Serving Car WashCar Wash Menufacturer Model Serial Number Apollo RPLF4A 721541 Size v�" Assembly Type ()() RP ( ) RP Detector ( ) PVB ( ) SRVB Water Supply Source: Check One ('t) Municipal Water System ( ) Other than municipal, non-community or private water system. See NR 811 and 812 for definitions. INITIAL TEST • RP relief valve13` check 2na check Opened at 3-I. 1- • PSID `1C Closed tight [If Closed tight Q Did not open ❑Leaked El Leaked Static '4 PSIDStatic 41 • PSID FINAL TEST Opened at PSID 0 Closed tight ❑Closed tight Static PSID Static PSID DETECTOR BYPASS ASSEMBLY INITIAL TEST RP relief valve 1" check 2' check Opened at PSID ❑Closed tightL7 Closed tight El Did not open Q Leaked ❑Leaked Static. PSID Static PSID DETECTOR BYPASS ASSEMBLY FINAL TEST Opened at PSID ❑Closed tight 0 Closed tight Static PSID Static PSID PVB/SRVB INITIAL TEST . PVBISRVB FINAL TEST Air inlet valve Check valve Air inlet valve Check Valve Q ened at PSID 0 Closed tight Opened at PSID ❑Closed tight ,LI old not open 0 Leaked Static PSID Static PSID ASSEMBLIES IN FIRE PROTECTION SYSTEMS Note: Include hose stream demand where applicable Forward Flow Test __ _ Designed flow rate GPM Actual flow rate GPM —Indcating Control Valves ❑No, one control valve open ❑ No. two control valve o•en Valve supervision: 0 Tarn•er switch 0 Locked Part(s)Replaced/Comments - — I HEREBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED BY ME PERSONALLY. Tester Name(print) Gregory A Kane II Registration No. B1702236Time of Day 11:)"• 0 Tester Signature Phone No. 715-441-8768 Date 1-4.a--Ike Cross Connection Control . Performance Test OWNER INFORMATION Please print clearly in ballpoint pen. Owner Name ' Street Address Kwik Trip, Inc 1626 Oak Street/PO Box 2107 City State Zip Code Owner's Contact Person Telephone Number LaCrosse WI 54602 Stacey (608)781-8988 FACILITY.INFORMAT,ION : ,• ,�_„ Facility Name Street Address Kwik Trip, Inc Store#281 16751 Fish Lake Rd SE City Zip Code County Prior Lake 55372 Assembly Location Assembly is Serving Mechanical Room Boiler Manufacturer Motiel Serial Number Apollo RPLF4A 707607 Size 11L,." Assembly Type ( r) RP ( ) RP Detector ( ) PVB ( ) SRVB Water Supply Source: Check One (4)Municipal Water System ( ) Other than municipal, nun-community or private water system. See NR 811 and 812 for definitions. INITIAL TEST RP relief valve © 18I check 2`id ck c Opened at a.- 0 P510 11J Closed tight M.Closed tight ❑ Did not open 0 Leaked 0 Leaked Static 1.'i" PSID Static ca a PSID FINAL TEST Opened et PSID ❑Closed tight ❑Closed tight Static PSID Static PSID DETECTOR BYPASS ASSEMBLY INITIAL TEST RP relief valyl it e L___na check Opened at PSID 0 Closed tightC❑ losed tight ❑ Did not open 0 Leaked 0 Leaked Static PSID Static PSID DETECTOR BYPASS ASSEMBLY FINAL TEST Opened at PSID 0 Closed tight ©Closed tight Static PSID Static _ PSID PVBISRVB INITIAL TEST PVBISRVB FINAL TEST Air inlet valve i ck,valve Air inlet valve Che_cig V_EIve Operred at PSID in Closed tight Opened at PSID ❑Closed tight ❑Did not open CI Leaked Static PSID Static PSID ASSEMBLIES IN FIRE PROTECTION SYSTEMS Note: Include hose stream demand where applicable Forward Flow Test Designed flow rate GPM Actual flow rate GPM _ Indicating Control Valves 0 No. one control valve open ❑ No. two control valve open Valve supervision: 0 Tamper switch 0 Locked Part(s) Replaced/Comments I HEREBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED BY ME PERSONALLY. Tester Name(print) Gregory,�!r,Kene Il ;; . Registration No. BT702236 Time of Day III-PO Tester Signature � � . Phone No. 715.441-6788 Date I`(5'".16 Cross Connection Control Performance Test OWNER INFORMATION Please print clearly in ballpoint pen. Owner Name Street Address Kwik Trip, Inc 1626 Oak Street!PO Box 2107 City State Zip Code Owner's Contact Person Tel LaCrosse WI 54602 Staceyeph one Number (sos)781-8988 P_ACiI�TY INFQRMATION -"" . Facility Name Street Address "-"""""" Kwik Trip, Inc Store#261 16751 Fish Lake Rd SE City W zip Code County Prior Lake 55372 Assembly Location Assembly is Serving Car Wash Irrigation manufacturer _ Apollo Model Serial Number RPLF4A Sire I 72-1-u Assembly Type (y)) RP ( ) RP Detector { ) PVB ( ) SRVB Water Supply Source: Check One (sC) Municipal Water System ( ) Other than municipal, non-community or private water system. See NR 811 and 812 for definitions. INITIAL TEST Eilreiief valve 1" check 2"tl check Opened at 3.6 PSID Zl Closed tight in Closed tight 0 Did not open ❑Leaked 8 ❑Leaked �_la Static • PSID Static PSID FINAL TEST Opened at PSID 0 Closed tight ❑Closed tight Static PSID Static PSID DETECTOR BYPASS ASSEMBLY INITIAL TEST RP relief valve 1 tc 2A°check Opened at PSID 0 Closed tight Cl Closed tight in Did not open ID Leaked ©Leaked Static PSID, Static PSID DETECTOR BYPASS ASSEMBLY FINAL TEST Opened at PSID ❑Closed tight ©Closed tight Static PSID Static PSID PVB/SRVB INITIAL TEST PVB/SRVB FINAL TEST Air inlet valve Check valve ' Air inlet valve Check Valve �Opened at PSID CI Closed tight Opened at PSID ❑Closed tight LIDid not open ❑Leaked Static PSID Static PSID ASSEMBLIES IN FIRE PROTECTION SYSTEMS __n ""' Forward Flow Test Note: include hose stream demand where applicable Designed flow rate GPM Actual flow rate GPM Indicating Control Valves ❑No. one control valve open ❑ No. two control valve open Valve supervision: ❑ Tamper switch ❑ Locked Part(a) Replaced/Comments I HEREBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED BY ME PERSONALLY. Tester Name(print) Gregory AKane II Registration No. B1702236 Time of Day = 1 Tester Signature, Phone Na. 715-441-8758 Date `^tS--I