The URL can be used to link to this page

Home My WebLink About19060037 Backflow preventer test�v ftA,a,y a� BACKFLOW DEVICE TEST �.` State Form 55788 (2-15) ?'•,.', INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT THIS FORM IS TO BE COMPLETED BY AN INDIANA CERTIFIED BACKFLOW TESTER. Customer . Device1 Customer name 2 Customer company Atapco 615-645 ATAPCO ...... _....... .._ 3. Customer address (number and street, city, state, and ZIP code) 615-645 W. Carmel Dr. Carmel IN 46032 4- Location of device (and address if different from customer) 5. Is the device a new assembly? ❑ Yes E] No 615 W. Carmel - West Side of Riser Room Replacing serial number: 7 Type of assembly 6. Type of service (] Domestic ❑ Fire ❑ Irrigation ❑ RP [D DC ❑PVB ❑SVB ❑ Air Gap ❑ AVB 8. Type of protection 9. Serial number of device ❑ Isolation 0 Containment 40681 10. Size of device 11. Manufacturer of device 12. Model number of device 3/4" 1 Wilkins 2000BM3 13. Additional information (optional) RP DC PVB/SVB Check Valve #2 Pressure Differential Check Valve #1 Air Inlet Relief Valve Initial Date: Held at PSID Held at PSID Opened at Opened at PSID Time: Closed Tight El Closed El Closed Tight ❑ Did Not Open ❑ PASS ❑ Leaked ❑Leaked El Did Not Open ❑ FAIL Check Valve Held PSID Final Date 4i9i19 Held at 1•6 PSID Held at 2 0 PSID Opened at Opened at PSID Time: aM^^^ El Closed Tight El Closed Tight PSID ❑ Did Not Open 0 PASS ❑ Leaked ❑ Leaked ❑ Did Not Open ❑ FAIL Check Valve Held PSID AIR GAP AVB Measured vertical inches above overflow rim : Supply size diameter: j Opened fully? [:]Yes ❑ No 15. Comments Tester Information 16- Name and e-mail address of tester 17 Company name of tester (if applicable) Tim Blue. tblue aOrvanfD com Initial 18. Telephone number 19. Signature and registration number of tester Tester ....................... 20. Testing equipment serial number 21. Testing equipment calibration date (mm/dd/yy) 22. Name and e-mail address of tester 23. Company name of tester (if applicable) Final Tim Blue. tblue@ryanfp.com I I Ryan Fire Protection 24. Telephone number 25. Signature and registration numbe egte Tester 317-538-5872 Bf17-5778 26 Testing equipment serial number 27 Testing equipment calibration date (mm/dd/yy) 02170824 3/28/2019 El By signing this backflow test report and checking this box, 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. Page 1 of 1 rmel Utilities City of Carmel Backflow Test Form Residential Information COMPANY INFORMATION Address Phone Number TESTER INFORMATION 9740 E 148th Street Noblesville, Indiana, 46060 (317) 770-7100 Select Tester From List - If tester is not on list, Select The First "Field Not on List" and then enter their information below BLUE, TIM_BF17-5778 Testers Email tblue@ryanfp.com Existing, New or Replacing Device Existing Device Serial Number 40681 Manufacturer of device Wilkins Device Size 3/4" Model Number Of Device 2000BM3 Type of protection Containment Type Of Service Domestic 0 Device Initial Test Pass or Fail Option Passed or Failed PASS Date Wednesday, June 5, 2019 10:10 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: Tim Blue Date and Time: Wednesday, June 5, 2019 10:10 RYAN 9740 E. 148th St. Noblesville, IN 46060 TPh: (317) 770-7100 Fx: (317) 770-0100 5 Year Internal Inspection of Sprinkler Piping and Valves Name of Property: Ataoco 615-645 Date: 04/09/2019 07:00am EDT Address of Property: 615-645 W. Carmel Dr. Carmel IN Buildin #: 645 Inspector Name: Tim Blue System #: North ,Page: 11 1 of 14 1 Previous Internal Insp.: None Identify System(s) involved: ✓ JJVVet =Dry Pre -Action Deluge Other: Internal investigation Data: (Note any foreign, organic and inorganic material) Type of investigation: ®✓ Invasive (demo, take apart) ❑ Non-invasive (video) Open and examine a flushing connection at the end of one main and describe condition. The end of the main appeared to be clear with no significant signs of debris or Foreign material. Remove a sprinkler toward the end of one branch line and describe condition: The interior of the branch line appeared to be clear with no significant signs of debris or foreign material. Dry Pipe, Preaction, Deluge, Alarm and Check Valves to be inspected internally every 5 years to verify that all components operate correctly, move freely and are in good condition. Qty of Dry Pipe Valves 0 Qty of Preaction Valves Qty of Deluge Valves 10 Qty of Alarm Valves 10 Qty of Check Valves 1 Results of Initial Examination: (Check box which applies) Yes No N/A 0 ❑ ❑ 1. The interior of the System Valve appears in satisfactory condition. 0 ❑ ❑ 2. The interior of the Cross Main appears in satisfactory condition. 0 ❑ ❑ 3. The interior of the Branch Line appears in satisfactory condition. ❑ 0 ❑ 4. The system may need further inspection, service or repair work to make further assessments. (i.e. Flushing of the system, tested for microbiological influenced corrosion, or partial replacement) Additional information: ®Visually showed owner ®Collected debris =Tagged Piping Recommendations: Witness (Owner or Lessee of the Property) Inspector (Ryan Fireprotection, Inc.) 04/09/2019 07:00am EDT 04/09/2019 07:00am EDT Date Date of Investigation 9740 E. 146th St. Noblesville, IN 46060 RYAN TPh:(317)770-7100 Fx: (317) 770-0100 5 Year internal Inspection of Sprinkler Piping and Valves Name of Property: Alaoco 615.645 Date: 04/09/2019 07:00am EDT Address of Property: 615-645 W. Carmel Dr. Carmel IN Building #: 645 Inspector Name: Tim Blue S stem #: south Page: 12 1 of 14 Previous Internal Insp.: None Identify System(s) involved: ✓ Wet Dry Pre -Action Deluge Other: Internal Investigation Data: (Note any foreign, organic and inorganic material) Type of investigation M Invasive (demo, take apart) ❑ Non-invasive (video) Open and examine a flushing connection at the end of one main and describe condition. - The interior of the main appeared to be clear with no significant signs of debris or foreign material. Remove a sprinkler toward the end of one branch line and describe condition: The interior of the branch line appeared to be clear with no significant signs of debris or foreign material. Dry Pipe, Preaction, Deluge, Alarm and Check Valves to be inspected internally every 5 years to verify that all components operate correctl , move freely and are in good condition. Qty of Dry Pipe Valves 0 Qty of Preaction Valves 0 Qty of Deluge Valves o Qty of Alarm Valves o Qty of Check Valves 11 The FDC check valve appeared to be operable with no issues. Results of Initial Examination: (Check box which applies) Yes No N/A 0 ❑ ❑ 1. The interior of the System Valve appears in satisfactory condition. 0 ❑ ❑ 2. The interior of the Cross Main appears in satisfactory condition. El ❑ ❑ 3. The interior of the Branch Line appears in satisfactory condition. ❑ E] ❑ 4. The system may need further inspection, service or repair work to make further assessments. (i.e. Flushing of the system, tested for microbiological influenced corrosion, or partial replacement) Additional information: ®Visually showed owner ®Collected debris Tagged Piping Recommendations: Witness (Owner or Lessee of the Property) Inspector (Ryan Fireprotection, Inc.) 04/09/2019 07:00am EDT 04/09/2019 07:00am EDT Date Date of Investigation