HomeMy WebLinkAboutHC1 - 2018 InspectionSubmission ID
Submission Date
This Form is being Updated daily with more options, All updated information can be found at
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Testers Email
Testing Company's Email
Customers Email
TESTER INFORMATION
Select Tester From List - If
tester is not on list, Select
The First "Field Not on List"
and then enter their
information below
Gauge Information
Phone Number
Calibration Date
Select Company or Self
COMPANY INFORMATION
Company Name Testing For
Phone Number
City Of Carmel Backflow Test Form 1
4136067892619812898
2018-09-24 09:59:49
tony.hughes@grunau.us
brian.sauer@grunau.us
erin.shepherd@cushwake.com
HUGHES, TONY_BF11-4199
4152475
(317) 872-7360
04-09-2018
Company
Grunau
(317) 872-7360
Address
SERVICE TYPE
Select Service Use
Residential Information
Manager or Commercial Information
DEVICE LOCATION
ADDRESS
HOA Information
Device Install Information
Existing, New or Replacing
Device
Device Information
Device Serial Number
Manufacturer of device
Device Size
Model Number Of Device
Type of protection
Type Of Service
6011 East Hanna
Suite A
Indianapolis
IN
46203
Commercial
Street name: Hamilton Crossing Boulevard
House number: 12802
City: Carmel
State: IN
Postal code: 46032
Country: United States
Existing
21056
Wilkins
6.0
375A
Containment
Domestic
Device Hazard Code
Hazard Code
Device Initial Test Pass or Fail Option
Selecting Pass will open the Final Test Page and Fail will open Initial Test Page
Passed or Failed
DC - Initial Test Results
DC - Final Test Results
RP - Initial Test Results
RP - Final Test Results
RP
Passed or Failed
Tagged
Date
PVB - Initial Test Results
RP
Yes
RP
Check Valve #1 Held At What PSID 8.0
Closed Tight Y
Leaked N
Check Valve #2 Held At What PSID 2.8
Closed Tight Y
Leaked N
Pressure Differential Relief Valve Opened At What PSID 5.2
Did NOT Open
Yes
YES
09/14/2018 11:30 AM
PVB - Final Test Results
AIR - Final Test Results
Sign and Acknowledgement
By signing this backflow test report, I hereby certify that I am familiar with the information
contained in this form and that to the best of my knowledge and belief, such information is true,
complete and accurate at the time of the test.
Testers Full Name:
Date
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Tony Hughes
09/24/2018 9:50 AM