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HomeMy WebLinkAboutbackflow inspection 2024PWS Name: Town ol Yarmouth Yannouth Fire Depl- Sta. # 3 BACKFLOW PREVENTION DEVICE INSPECTION AND MAINTENANCE REPORT FORM PWS lD #: €51000 520 Buck lsland Rd T€st Typo Facility Na,ne Facilily Addre36 Yarmouth Fire Dept. Sta. # 302673 City/Town State Zipcode Facility Owner/Responsible Party City/Town (M) 508-398-2212 Spdnklor Room State Zipcode Contact PoBon 90377 Exact location of cross.connection protected by device Cross-connaction lnfo lD # Supplemont l protoclion at mater required Device lnlolmation Dcvice typo DC Uake Model 2000ss Size Sorial 156333 M.teri.l Stainless Steel Shutoff Valvc Typo OS&Y By-pass No lnrtallation Horizontal lnstalhdon Requlr.d By: State Phone ext. A16 repair p.rts available on site? No ls devic€ installed on fire protec. systom? Yes Hazard Level: Low Secondary Supply on System: No T€st Kit lnformalioh @ 1at Check 2 2nd Check 3.2 TighULeaked Tight TighULeak6d Tight Air lnlet Check Valve T.3t Oet€ 912912022 2nd Shutoft Valve Test Resull Passed Make & Model Serial# and Last Calibration Mid-West 845-3 974477 lKit l) Calibtated 21312022 *Backflow Device Test Conducted by a MasSDEP Certified Backflow Prevention Device Tester Jefr Pa et 32335, 11612024 Tester Signaturc FacilityOwner/RepresentativeName Title Ownet Signature '11. br&,ow p@@tkn bn@ 6iL<l c |6n, tb dding s.ps dD 6qui/d Dy tt rr.esd@te Otiitd,g w.tet R.gut t rs 'ftD ffit dth. dc"ic, nud &6h dr evk olaM6g.r,@trl ri..^$dy'aib, d. lL.rr.tr6ds /r.nted ,tr q.iaLbr olbrl@ntud to prlon t E ,essry apat ihn fa,.aa 111) ..lon la. dtt. ol UE /,lutu tod q ft@ th.d@6ryottt d.led.s 6qund byth. u.t .dusn. avinking wat t R.gut ti@t 310 cuR 22 22(13)(4 fh ocai.d d.n6 tud b..*,!d. 'a B.cHb* t\.9.at@ D.vi@ R.prthb@fbn t, R..r6t Rapon F@ Nd h. .ottdct dto tupotttho 6p.it(.) csnud.d.n tth. c-t .t 6.!n tlailing Address Deputy Chisf Sawyer Phon6 # - Auxlll.ry Supply No DCVA PVB I heteby ccdlficd ttat t hay. perRonally aasaad ha above backllow prevention dcvlcdzssambly in accordanca ulth lhc mathod anat Ptoc.dun At t I w.t l'ained, and ahc tcst resuft ls true ead shows thal ahe devlcal.ssornbly ts ln proper oper.tlng condltion. (Stgnaaufts nquh.d) Comment3: B.ckflow f.ster Name, lrassDEP Cen.lDi, E plretlon Datr, 'Backf,ow Devicc fest Witnessed by a Facility Ownat/Ropresentativ.