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Home My WebLink AboutParkwood VI PBPWD006 Backflow Domestic 5-29-19Systems Service Koorsen �I L FIRE & SECURITY F u J.1:hi'.1'1 L1.1to o Ill J.:0f).1 1V P01:,7, ., :LPI 6X2130 0 Liftt .� ]it'C , 1',11rj1)Ci(iD VT 01, s'vI Il Ll 11 C...., L, U 'it() (,.Val, 1.U1% .t; I OR'f' - 'P(r 'I, is t.lir.,`,! Typ of Sy le M f Ire Insl `. oInspecdon Company Name Last Service Date Material Used � ProUlains Fauna: Date The shove Inspection Is matle Forihe purpose o(checking the mechanlcel end/or electrical operation of determine or guarantee proper capacity. engineerin➢ or original Inslallalion. Vendor shell not ho responsihle (or the Improper operation of any Inspected equipment that, alter servicemen has lok promises, has been discharged, Vandalized, tempered with or damaged. The reverse of this agreement is incorporated herein. Please read carefully. We are not an Insurer. Our mauimum Ilehillly Is (hutted to $260.00. User acknowledges recelpl of copy and that he has read and understands reverse side of agreement. Customorl_StgOature , / /Sale I Technician's Sf_gnature Data Sub•Total KF-0faC Rev. 1/13 / BILLING DEPARTMENT Date The shove Inspection Is matle Forihe purpose o(checking the mechanlcel end/or electrical operation of determine or guarantee proper capacity. engineerin➢ or original Inslallalion. Vendor shell not ho responsihle (or the Improper operation of any Inspected equipment that, alter servicemen has lok promises, has been discharged, Vandalized, tempered with or damaged. The reverse of this agreement is incorporated herein. Please read carefully. We are not an Insurer. Our mauimum Ilehillly Is (hutted to $260.00. User acknowledges recelpl of copy and that he has read and understands reverse side of agreement. Customorl_StgOature , / /Sale I Technician's Sf_gnature Data Sub•Total KF-0faC Rev. 1/13 / BILLING DEPARTMENT �,✓� �ti g�zagy-� BACKROW DEVICE TEST ' elele Fo[m 66788 (2.1a) INDIANA DEPARTMENT of ENVIF1oNMENrAL MANAGEMENT THIS FORMIS TO BE Co MPLETEU BYANINDIAIVA CERTIFIED BACM0W TESTER, 1 4ryvG wood V = umber and street erk stafe, 15 4CrN <"4- Q.Fite ❑ a fa Par- Wand ✓Y tiGz•v�a tiro device a new EI RP Q DC Q PVB ❑ SVD ❑ Air Gap J] AVI3 9. Serial number of device H5ZS5? . Check Valve Ix1 chock Valve tk2 Pressure Dfffemntial Initial RAImi'Valve Airfnlet Date (udda4y):5 24 Held at $,_%% PSID Hold Time: I pm PSID at Opened at Z, O Opened at� PSID Ff Closed Tight Closed Tight PSID ASS ElEl baked Did Not Open Q FAIL ❑ Lealcod ❑ Did Not Open ...__ , Check Valve Held PSID Final Date rmuvwW:Held at PSID Held at pS1➢ Opened at Timer Openedat� p PSID El Closed Tight ❑ Closed Ti Tight PSID ❑PASS g Q Did Not Open Q Leaked � FAIL ❑Leaked El Did Not Open ' Check Valve Held PSID AIR GAP Measured vertical inches above overflow dm : S ly size diamoter: AVB 15. comments 0 sited ii&? ❑ yes ❑ No itio 16, Name azld a -mall address f testhr 17. Company name of tester (fopplicab/e) Initial 1B. Telephone number 19, Si furs and mgisiratlon number o tester fC�'"se.-._. t Tester t7— a7 ^ G 8Z 20. TOest ng equipment serial or 21, Tearing equipment calibration date (mm/ddlyy) 2Z Name and CCe-mall address of fester ^3 ^ 1 Final 23. Company name gftester (riapp/lctnble) Tester 24. Telephone number 25, Signature and registration number of tester 26. Tearing equipment serial number 27. Testing equipment calibration date (mm/dd/yy) []Byslgningthis hackf(owtest report and checking fhtsbex,lhereb certi that IamfatniliarwlththeInformation this form and fhat to the hastofmy knowiedge'and belief, such info) n is true, complete and accurafithe time ofth In Page 2 of 2 WM�3475 t3 Wp dddd BACKFLOW DEVICE TEST sidle Fun 867611 (2d5) ' INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT AFB THIS FORNIIS TO BE COMPLETED BYAIV INOJANA C,fRTJFIED BACKPLOW TESTER, p u_ 1. Customername 2. Customercompany �Qr lc ood ✓T Pq. L� odd ✓T & Customer address (number and street, a*,, state and7JP codo) enf S" d:g a at;r TN t6zWo 4, Locai(on ofdevice (and addmssifdifferent from customer a: fir, O� ) 5. Is the device a new assembly? • ❑ Y2TNo BTypeofservlce Replacing serial numb r ❑ Fue ❑ 1Mgatian RP l 0 DC� ❑ PVB ❑ SVB Q Air Gap [] AVB g. barn number of dovice containment ry 7.7a Nanufaoturerofdevice 92.Model numherofdevice ' ... 11 a � 007M z qT- Chock Valve 1kl Initial Date i y9;5/zof Held at f q PSID Tim e:2; 3o prl Closed Tight ASSL El FAIL Final Date tim✓1 dV): Time. LIP PASS❑ FAIL IR GAP CheckVaive#2 PressureDitferentlal---^ -- Rel[of Valve Ah•Inlet Heid a/t_ PSID Opened at �•o Opened at. PSfD L`7 IL Ti Tight PSIQ 9 ❑ Did Not open ❑ Leaked [] Did Not Open Check Valve He PSID Held at,� pS(D Opened at Opened at_ PSIp ❑ Closed Tight PSID [] pia Not open [] Leaked ❑ Did Not Open Check Valve Held.__ PSID '"""�,�`-�Y � kry � 17. company name of fester (Ifapp/fr Initial :4.�},�o ,m lCuorre t6. Telephone number tg. Si cure and registration numbero taster ---- Tastes. r1— Q 1 ^ G LotM 20.Testin9equipentserfal er 2t. ToMin 0 i g equipment calihmtion date (rem/tldyy) 1 Final 22. Name and e-malladdressoftester 23.Company name oftester (ifapppc Tesfar 24. Telephone number 25, Signature and registration number of tester number 27 [] Bystgnfng fttls hackgowtestreportand rheckincj this box, 1 hereby certify that I am familiarwith fhaihformaffon contained fn this fosm and that fo fhe best ofmy Imowledge'and belief, such fnfotmafion is {rue, complete and accurate of the fired ofthe test Page 2 of 13ACKFLOW DEVICE TEST ' G Mel&Fan 6578B(2-16) ' INDIANA DEPARTMENT OF ENVrooNMENTAI, MANAGEMENT THIS FORM IS TO BE COMPLI~TEO BYANIND/ANA WRTIFIED BACIPLOIATBST, 'R. (Dar �wced VT 2. Cal stomerCargil y 3. Custamar address (num6arand street, city, slate, and ZJP code) Goo G 9G+� to T cl 9 a gilts inl 4, Location of devioe (and addressif different from customer O_ �•�_ _ . _ I % W Is1he davloe a naw a. ]nifi'ral Dale rmmvcwl:' Q FAII. Final Date (mmaaI Time: Q PASS ❑ FAIL Initial 16 Telephone Tesfar t 2g. Testing eq d z 22. Name and Final 24. Telephone Tester Q.Fire Q IrdgaBon RP Q DC Q PVB Q SMI Q Air Gap ❑ AYS 9. Serial number of device Q containment 3`1 i o �► wanufacturerofdavice '12.ModelotgrIofdevice na�anWaEtc Oo9t`'IIQT� -- Check Valve#1 Pressureb' _-°r'iavts Check Valve#2 alvential Arinlet Relief Valve Held at g.�p51D Held of PSI➢ Opened at Z.$ Opened at______PSI➢ Closed Ti ht PSID 8 closed Trght Q Did Not Open ❑ Leaked ❑Leaked Q Did Not Open Check Valve Held PSI➢ Held at PSID Held at^, PSID Opened at Opened at_- PSID Q�ClosedTight ❑Closed 'fight PSID QDidNotOpen Leaked ❑ Leaked Q Did Not Opan Check Valve Held PSID 27. Canpany namo Company name Q Bys[gning this hackflowfasE mportaud checking this box,1 hereby certify that! am familiarwith the ihfolmation contained in this form and that fo the hest of my knowledge'arsd belief, such imformatien is true, complete and accedrate of the time ofthefest Pane 2 of