HomeMy WebLinkAboutCross Connection Test
Safety and Buildings Division
P.O. Box7302
Madison, WI 53707-7302
Telephone: (608) 266-0521
Fax: (608) 267-0592
TTY: (608) 264-8777
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INSPECTION SERVICES DIVISl<m:irsonallnformation you provide may be used for secondary purposes (Privacy Law, s. 1504 (1) (m)].
Owner Information Please rlnt clearl In ball oint n: Additional Information on back a e.
Owner Name Street Address
Merc Medical Center 500 S. Oakwood Drive
City State Zip Code Owner's Contact Person
Oshkosh WI 54904- Tom Laabs
Pro ect Information
Project Name
Merc Medical Center
City
Oshkosh
Assembly Location
Decontamination .1 E005 . Pass throu h washer south
Manufacturer
Watts
Size 1/2"
NOV 2 3 2007
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6
Telephone Number
Zip Code
54904
Street Address
500 S. Oakwood Drive
County
Winneba 0
Assembly Type: 181 RP
Model
009SS
o RP Detector
DDC
PVB/SVB
INITIAL TEST
18t check 2nd chec RP relief valve r;)
Iii Closed tight Closed tight Qpened at ~ ' a' PSID
o Leaked Leaked 0 Did not open
~~~!i?.... .._?~. ~.. .:~I?................... ~t~~~.... .;.?~ .g... ..~~'.~....... ........... _..... ............................ .......... .........
FINAL TEST
....., .Closed tight o Closed tight Opened at PSID
ltlc PSID Static PSID
DETECTOR BYPASS ASSEMBLY INITIAL TEST
18t 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 Old not open
PSID
Opened at
PSID
PSID
: PRESSURE V ACUUMBREAKER FINAL TEST
! Air Inlet valve Check valve
: 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 Did not open 0 Leaked
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 Static pressure PSI
No. of nozzles flowed Nozzle size Pilot pressure
Inlet flow pressure PSI Outlet flow pressure PSI PSI
......... ..- .................... -......................... .... - ..... ............ ... .-................ -.... ...... -......... -... .... -.......... ..'... ........ ....... .......
Indicatlna Flow Test
o No. one control valve open 0 No. two control valve open Valve supervision: 0 Tamper switch 0 Locked
Part(s) Replaced/Comments
. .~REBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED SV.MV PERSONALLY.
Tester Name (Print) ~N'C~_,~)( ~ Regl_ No. 244112 Tim. of Day 9J JC; ~
Tester Signature __ll._ Phone No. (920) 759-2500 Date 11_/~-O'7
.
880.9927 (R.8198)