HomeMy WebLinkAboutCross Connection Test (2)
~ @~ @~~. .. 8afetyand Buildings Division
~ ~ ~ 1!,A88~ P.O. Box 7302
NO/! ., ~ [jjJ~ Madison, WI 53707-7302
NOV 23 Z007 <: 0 2007 ~ U~ ~:pr~;~:2~~~5~~6-0521
.r~MJJ~~:r;:~~.g~~.1ENT TTY: (608) 264.8777
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INSPECfION. ::;, Personal Information you provide may be used for secondary purposes (Privacy Law, s. 1504 (1) (m)].
Owner Information Please rlnt clearl In ball oint Additional Information on back a e.
Owner Name Street Address
Merc Medical Center 500 8. Oakwood Drive
City State Zip Code Owner's Contact Person
Oshkosh WI 54904- Tom Laabs
Pro ect Information
Project Name
Mer Medical Center
City
Oshkosh
. Assembly Location
Decontamination -1E005 - Pass throu h washer north
Manufacturer
Watts
Size 112"
Telephone Number
Zip Code
54904
Street Address
500 8. Oakwood Drive
County
Wlnneba 0
Assembly Type: 181 RP
Model
00988
o RP Detector
DDC
D DG-9etector
INITIAL TEST
1st check
[3..C1osed tight
o Leaked Q /'
Static r, Q PSID PSID
..........................-......................................................................-....................................................
FINAL TEST
..., Closed tight
ltic
RP relief valve 1..1 0
Opened at 7..
o Old not open
PSID
PSID
o ClOsed tight
Static
Opened at
PSID
PSID
DETECTOR BYPASS ASSEMBLY INITIAL TEST
1" check 2nd check
o Closed tight 0 Closed tight
o Leaked 0 Leaked
Static PSID Static PSID
.......................................................................................................................................................
DETECTOR BYPASS ASSEMBLY FINAL TEST
o Closed tight 0 Closed tight
Static PSID Static
RP relief valve
Opened at
o Did not open
PSID
PSID
Opened at
PSID
: PRESSURE VACUUM BREAKER FINAL TEST
: Air inlet valve Check valve
1 Opened at PSID 0 Closed tight
: Static
I
!
PSID
PRESSURE VACUUM BREAKER INITIAL TEST
Air Inlet valve Check valve
Opened at PSID 0 Closed tight
o Old not open 0 Leaked
Static
PSID
ASSEMBUES IN FIRE PROTECTION SYSTEMS Note: Include hose stream demand where applicable
Forward Flow Test
Designed flow rate GPM Actual flow rate GPM Static pressure PSI
No. of nozzles flowed Nozzle size Pilot pressure
Inlet flow pressure PSI Outlet flow pressure PSI PSI
......... ......- ...... .......................... -............................................ - .......... ............. ..-.......................... -.......... -.. ......... -...... ..--................ ..... .....................
Indicatina Flow Test
o No. one control valve open 0 No. two control valve open Valve supervision: 0 Tamper switch 0 Locked
Partes) Replacecl/Comments
'lREBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED BY MYPERSONALL Y.
Tester Name (Print) Nick Grams Registration No. 244112 Time of Day 1 ~ J C> Ilh.,
Tester Signature ~-'-'1. i..fl /1-.- .-/' Phone No. (920) 759-2500 Date II ,,'If;.-:''''o 7
880-9927 (R.819B)