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24B-086 (7) a "a tioti CITY OF NORTHAMPTON, MASSACHUSETTS • DEPARTMENT OF PUBLIC WORKS , 0 125 Locust Street , Northampton, MA 01060 413-587-1570 Fax 413-587-1576 George Andrikidis, P.E. Director, City Engineer Guilford B. Mooring, P.E. Assistant Director of Public Works April 29, 2003 3 City of Northampton 240 Memorial Hall Northampton, MA 01060 Attn. Brett Jacobus Ref: Backflow Device Test Failure Dear Customer: This notice is to inform you that your Backflow Prevention Device has failed the testing specification required by the Northampton Cross Connection Control Program, and the State Department of Environmental Protection regulations. Please refer to the attached failed Backflow Prevention Device Inspection & Maintenance Report Form for appropriate action. In addition to the attached failed test form is a Device Repair Information & Retest Report Form. This form must be completed and signed by a licensed plumber for domestic water or a certified fire sprinkler fitter for fire protection systems, and signed by the plumbing inspector or building commissioner's office after the backflow device has been repaired. Arrangements can be made for the inspector to meet with the contractor on the day of the repair, if needed. If these arrangements are not made, this department must be notified of the repairs in order to reschedule retesting of this device. A successful Retest of the device must be completed by the Department of Public Works Cross Connection inspector within two weeks of the receipt of this notice. If you have any questions, please contact this office. Very truly yours, Xf,e1)t, George Andrikidis Director of Public Works cc: Building Commissioner's Office Enclosure r • Department of Public Works 125 Locust Street BACKPLOW PREVENTION Device TEST STATUS Ininal I I Northampton, MA 01060 INSPECTION AND MAINTENANCE Retest [ 1 413-567-1570 REPORT FORM Supplier Annual [L]' ////.0..3 SupplierSemlannuai [ ] Inspection Date PWS ID# 121400 ivory Name 26 Carlon Drive 1043 DEP Owner ID# Northampton Fire Department Owner of Device DEP Tester Certificate* Xg Contact Person Chief Brian Duggan 214178480 DEP Device ID a Phone+► 413-587-1032 Device Type: [ ]RPPA [ ] Bronze 240 Memorial Hall [ I DCVA [ X]Iron IUailingAddress flake WATTS Model DCDC Northampton, Ma 01060 26 Carlon Drive Size 4 Serial# 117386 Device Address Northampton, Ma 01060 Containment Device [ X]Yes [ I No Required by: I X]State [ I Local Mechanical Room Fire Sprinkler Main Exact Device Location NONE By-Pass [X]Yes [ ] No Device x Not Visabte Secondary Supply or System Valve Type [ 1 Rail [ 1 NRS [ ]OS&Y [X]Butterfly [ ]Other Check Valve No. 1 Check Valve No. 2 Differential Pressure Relief Valve Test Before Repairs Leaked [ I Closed Tight PI Leaked AI Pressure drop across Opened at `�/ PSI ���� Closed Tight [ I Reduced Pressure First Check 3, PSI Q rOS,t— 'Describe Repairs NA'Test Closed Tight [ 1 'Pressure drop across Goned Tight I I Opened at PSI Reduced Pressure Date / / Flat Check PSI Iri+peeffon Rout PASS [ I EAII[", If device failed,describe the problem Whetted by: (SI®►atures) M,,Q ec /i `/eJ ,p7/� AA Owner's Representative !i' /4 c ' L eii PWS Official % 'List parts&Materials used: IAA-DEP Cartffied Tester DEP Official BACKFLOW PREVENTION DEVICE REPAIR INFORMATION & RE-TEST REPORT FORM (Print Clearly) Was a plumbing permit petitioned for the repair of this backflow prevention device? D Yes ❑ No Repair(s) conducted by *: / / MA Cert.Plumber Name MA Cert. Plumber ID# Cert. Exp. Date Signature Date Plumbing work inspected by: / / Local Plumbing Inspector's Name MA Cert. Plumber ID# Cert. Exp. Date Signature Date * A Massachusetts Certified Fire Sprinkler Fitter must conduct the repair(s) of backflow prevention devices installed on fire protection systems. MA Certified Fire Sprinkler Installer Name MA Cert. ID# Cert. Exp.Date Signature Date Repair Date Check Valve #1 Check Valve #2 Relief Valve Cleaned only ❑ Cleaned only ❑ Cleaned only ❑ Describe Repair(s) Replaced parts ❑ Replaced parts ❑ Replaced parts ❑ List of part(s) & material(s)used Leaked ❑ Leaked ❑ Leaked ❑ Re-test Date Closed Tight El Closed Tight ❑ Closed Tight 0 / / Held at psid Held at psid Held at psid Re-test Result PASS ❑ FAIL * ❑ * The above re-test/inspection is certified to be true. Test conducted by: / / MA-DEP Cert.Tester Name MA-DEP Cert. Tester ID# Cert. Exp. Date Signature Date Test Witnessed by: Owner's Representative Name Title Signature Date ** If repaired backflow prevention device fails the re-test, it must be repaired and re-test and a Backflow Prevention Device Repair Information &Re-test Report Form must be fill out. OPS/XCONN/REPAIR&RETEST FRM(Revised 08/20/2001)