HomeMy WebLinkAboutCross Connection Control Performance Test - 01/26/2005 ,�
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commerce.wi.gov � ����aX d 6021dings Division
isconsin Cross Connection n,WI 53707-7302
DepartmentoiCommerce performance Test FTTY:((608,�264$777
FEB 2 3 2005
; _ ; ; http://www.commerce.state.wi.us
Requlated Obiect Number: � �, ` �> i � ,` � http://www.wisconsin.gov �
Personal information you provide may be used for seco� a s �15 e4�1�(m)]. �
OWNER INFORMATION Please rint clearl in ball oint n. AdditiorYa���ti���� � � � �
Owner Name Street Address
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City � State Zip Code Owner's Contact Person Telephone Number
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FACILITYINFORMATION _.. ; .; _. "
Facility Name Street Address
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City Zip Code County '
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Assembly Location ,. - �
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Manufacturer ' . M�e� Serial Number
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Size Assembly Type �RP ❑ RP Detector ❑ PVB/SVB j
INITIAL TEST
RP relief valve 1 ST check 2nd check
Opened at PSID ❑Closed tight ❑Closed tight
�Did not open �Leaked ❑Leaked ; �";
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Static PSID Static '� -�� PSID
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FINAL TEST � �
Opened at __ PSID �Closed tight - - G�Closed tight I
Static t = PSID Static �, �i PSID
DETECTOR BYPASS ASSEMBLY INITIAL TEST �
RP relief valve 1 ST check 2"d check 1
Opened at PSID ❑Closed tight Cl�osed tight �
❑ Did not open ❑Leaked ❑Leaked j
Static PSID Static PSID
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DETECTOR BYPASS ASSEMBLY FINAL TEST i
Opened at PSID ❑Closed tight �Closed tight i
Static PSI D Static PSI D
I PRESSURE VACUUM BREAKER INITIAL TEST ; PRESSURE VACUUM BREAKER FINAL TEST l
Air inlet valve Check valve ; Air inlet valve Check Valve !
I O ened at PSID ❑Closed tight ; Opened at PSID ❑Closed tight l
�Did not open ❑Leaked Static PSID �
�I Static PSID � �
ASSEMBLIES IN FIRE PROTECTION SYSTEMS Note: Include hose stream demand where applicable i
� Forward Flow Test
� _____________________ Designed flow rate_ _GPM ^^ ^ Actual flow rate GPM I
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'�I Indicatinq Control Valves '
� ❑No. one control valve open ❑ No. two control valve open Valve supervision: ❑ Tamper switch ❑ Locked
� Part(s) Replaced/Comments ��v ;�'�,� <` t __' _--. ;" �t . ,• `v l�; -�
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; I HEREBY CERTIFY THE TEST RESULTS ARE TRUE AND THE TEST WAS CONDUCTED BY ME PERSONALLY. ��
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I� Tester Name rint `� : � ' � .._f , , ,�, , .' ' y"�, �i�. `�l
(p ) � � Registration No. << � Time of Day
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� Tester Signature - Phone No. -'f`� � Date ,'�--��,' -�`!
�I SBD-9927(R.5/04) White-Department of Commerce,Pink-Tester,Canary-Owner,Blue-Surveyor
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