HomeMy WebLinkAboutParkwood VI PBPWD006 Backflow Fireline 5-29-19Systems Service
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INVOICE TO; SERVICE LOCATION:
-?li 1(t Ctn h-0A 41).L fVG 1 .17-, `r
21
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600 9F,`Oji :.-I _'tS 1,.'.10It
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No, of Podel l¢
TechnlcNns Sarvlce Zone podal Travel Hrs, ArrMed napaded
"� t 1 I t O� l'lh 113: Owl FM7
Type
Manufacturer
f System
e 1❑T lCall
III - Roullne inspecd¢n
Performed:
Company Name
Las! Service Date
Material
Used Tool -31 (Each IAmowd 'Date I7¢chnician IHrs. (Rate
The above tnspeclion Is made for the purpose ofchecking the mechanical andlor eleolrical operetton of the equipment and not to "'
determine or guarantee proper capacity, engh(eering or original inslallallon.
has been
urged, vandalized,
war or derangedany inspected equipment that, after serviceman has fefl promises, Labor
H
has been discharged, vandeilzatl, tampered with or deranged. Labor Hra.
The reverse of this agreement is incorporated herein. Please read carefully. We are not an Insurer, Our maximum liability is Total
Iballed to $260.00. User acknowledges receipt of copy and that he has read and understands reverse side of agreement. ,Material:
Cust rperjy Signature A z z yore 17echnician's Signature Date Sub•Total
Print CusfomerN me �aL�Jf/ NiJ.C`7",Q./. dz—���
I(FArac Rae i/13 / "�7"r�1 BILLING DEPARTMENT
"iBACKROW /
EVIGE TEST
INWANA DEPAMMENT OF ENVIRONMENTAL MANAGEMENT
FORIWIS 710BECOMPLnTED:
'.aDe/
l tig
elm
••-�-�� e._xusfoiner
'7fcefnform tion^;=
Cuslorneradowaa (number and stroint, QUY, state, and ZIP code)
I� land RdEfress It amenunt from customer)
Is the dav
■
serviceGiType of
B. Type of Protection
■ PVH ■ SVB [1AJrGqp EJAVB
HIP
El Isolation
Containment --
u ; '3.
�. ➢ _- - _ 9A. estMe sureinents
➢ 41�
r
I ChecRVa1ve#j CheckValve#2.alp
- Initial Air Inlet
D. Held a
IHold at , Opened at
Opened at� /
pap
V /
Leaked 1 ■I. NotOp
17JPAL El Leaked 11 Did Not Open Check Valve Held
Final
I.
r Opened at. PSID
PASS x
El Did Not open
AIR GAP
Mb4sured vertical inches above averflow tim: supply size diameter., AVEI
15a comments I. ■ yes■No
:
[] Bys➢going thfs 6ac1d1owtesEreporE and checidn� fhis box,1 hereby cerliCythaf I am fam➢l9arwiEfi fheihformation contained in
ih➢s form and fhaE Eo tho 6esE of my kttowledgo"and 6eliof, such informafinn is true, complete and aacmafe attha limo w the felt
Page 2 oil
it 11 C4CFL,OW DrWICE TEST
at
Font 66j66 (2.
ka X�N ,
INDIANA OEPARTMF.M' OF ENVIRONMENTAL MANAGEMENT
7E/IS FORIP113 TO B.E COMPUiTED BYANINDIANA CERTIFIBD BACKFLOI//TESTBR.
I. Customer name ❑ -
Parlcwood VT 2. Customer company
i. Customeraddress(numberand sGeet, city, state, and7(P code) ParlGwoad ��
Gmo � 46w- St- T,...ti:a�.a of:s, �ni �E6z<lo
Loeailonofdov1 (and addtass/fdilferentfromcttslomerJ 5,Istfiodevlaeanewassembtw� fwoo
„�/ 17. Typo O
❑ Domestic LI Firo Q Irdgatlon q RP
fpenechon
f'I fenl�n..., Iu —x 9. Serial r
Initial
Date t wouvw:�
Ly'pASS
_- Q FAIL
Final
Date (mm/abW
Time:
❑ PASS
FUJFAIL
Initial
Tester
Final
Tester
check Valve#7 I Check Valve#2
Held at 3_4, pSID
Closed Tight
❑ Leaked
Held at 3T5 PSID
Closed Tight
❑ Leaked
❑ 'VB q sys q wr Gap ❑ Avs
evice
I'zv3 ,
Plrssure bitferential ..
R811efYalve A r inlet
opened at Opened at_ PSID
PSID—�
q Did Not Open
❑ Did Not Open
Check Valve Held,_, pSID
Held at`� p51p Hefd at, pS70
Opened at_, Opened at_ PSID
❑'ClosedTight El Closed Tight PSID
❑ Leaked Leaked Did Not Open El Did Not Open
Q ❑
Check Valve Held _ pSID
e-mail
Company Hams of fe
_lCcwr.ce._
q this onn anrllfhat to the Besto fmy knowledge and he]e f, such nfonnatlon is true, �mplefe a)nd accurateatfhefi je ofthe test
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