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)