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HomeMy WebLinkAboutPNC Carmel, IN Backflow Report�s=i�Vl��� �I_li�'rS '�i_ I '� �'�'�_'�`'� �415!r c *,� TERMS ItlG i` CUSTOMERBILL TO JOB NAME $LOCATION U1 JC)"i951 7 �. IC)HN JCIFiDf;IV JOF;nAN CIViE�I�IiTSLB �f�RDAN PChl4:'C-UD 11U117 ALLSSUI�lVILLF_ RD �'TL 21� 1i405 l� PEIV�ISYLV>�1�ITA REQUESTED START DATE REQUESTED FINISH DATE CUSTOMER PHONE JOB PHONE i �1Gi i-�7%U 31 �i41�-£t3U7 JOB DESCRIPTION � 7i9 //� --- UlF.iit/ff fsll �Cr��t1L °Y No. of Podal to QU�IipC technician aervirn>nw HF.6UILu INEiGSi I1t F1.PGLII,E GACk;LOR! iNAi HAD fP.ILHU Ai iih1E OF 'iNE RISPECiiUh. GtiUIifLUI" ihirfi: PIA"i'i51 350k/ StHigL t'•_33dU1 IACt=.TicB: 9iSER I?UORI. SpcCIAL lldSiRllCiIUNS JONN JUAUAH 3t1-did-E3U7 �i��/ih JUb NUMtSt SC=P,'✓:(SQL—rJ1 URIC Oujl4/%UI.�'i P.O. NUMBER 0 1 1. �s -7"oar, �I � �x��yt� Poana: ❑Trouble Call ❑ Routine Inspebtlan ICY$ �^sA,a�` d- yn,Ps rn�/r i8 IZ�ivYc! �- �4esf /L,� �) J=i�/2+e v �.'t I l Ai�ii �?� •¢ 2>rb�,%f 1G' zS �cSfS-..t e%� �c rt ✓�^-�f� �1�Jrc� qt . Material Used Each Amount Date Technician Hrs. Rate Labor Char e G✓�)K,µS 3.SNA y Is t ctir /G 71��/cj S/?i 5 � w;r��s 3so� a��,� �,� — 3 � I�-t�.��, C�+� #a- Materiel Total Forwertl The above inspect{on is made for the purpose of checking the mechanical and/or electrical operation o(the equipment and not to determine or guarantee proper capacity, engineering or original installation. Total Labor Nre. Vendor shell not be responsible for the Improper operation of any Inspected equipment that, after serviceman has left premises, hea been tlischarged, vandalized, tamperetl wish or damaged. FE 1 2 3 4 5 The reverse of this agreement is Incorporated herein. Please read carefully. We are not an Insurer. Our maximum liability Is limited to $250.00. User acknowletlges receipt of copy and that he has reed and derstands reverse sitle of a eemeni. Total Materiel Customer's Signature Date Technlcl Slgnetu pate pa} � s,4� %%�e/ � 6uh•Totel salearax '+riot Customer Nama � f ��Y� � �� � CF-099 (6l101 TOtel Dug �reee� ACI''�6 LlU)W DEV11GL t � S T f Al)411� SI to feral 5788 (2-15) y� INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT THIS FORM IS TO BE COMPLETED BVAN INDIAWi CERTIFIED DACKFLOW TESTER, �, I _v '�"nnXXYaIaTe.]_ QnhiCGN 1. Customer name Jr,� _^ 2. Customer company 3. Customer dress (number and street, city, state, and ZIP code) 7 !d os �/ Penns /���.�, 4. Location of device (and address if different from customer) 5. Is the device a new assembly? ❑ Yes ❑ No 1?4rl %N' Re lacing serial number: 6.Type of service 7. Type of assembly ❑ Domestic ,� Fire ❑ Irrigation ❑ RP t-DC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB 8. Type of protection 9. Serial �I umber of device ❑Isolation Containment 'd�33y0 10. Size of pievice 11. anufacturer of device 12. Model number of device ' 'I l,J,' lt�s 3S0 13. Additional information (optional) l Tr(k KL ui(dnn " Initial Date (mmdayy): Time: ❑ PASS ❑ FAIL Final Date (ndddW):%�d�h5 Time: 2vtS ® PASS ❑ FAIL Measured verb 15. Comments Initial Check Valve #1 Held at � PSID [I Closed Tight ❑ Leaked Held at y a PSID Closed Tight L1 Leaked e-mail address of tester Check Valve #2 Held at � PSID El Closed Tight [I Leaked Held at y o� PSID 49 Closed Tight ❑ Leaked size diameter: 19. Signature and registration Pressure Differential Relief Valve Opened at_ PSID ❑ Did Not Open Opened at _� PSID ❑ Did Not Open Airinlet Opened at _PSID 0 Did Not Open Check Valve Held _ PSID Opened at _PSID El. Did Not Open Check Valve Held _ PSID Company name "cI 20. Testing equipment serial number 21. Testing equipment calibration date (ram/dd/yy) 22, Name and e-mail address of tester 23. Company name of tester (if applicable) Final Jake Mobley Jake.Mobley@koorsen.com Koorsen Fire & Security 24. Telephone number 25, Signature and registration number of tester Tester 317-710-3090 BF16-5584 26. Testing equipment serial number 27. Testing equipment calibration date (mm/dd/yy) 04161499 12/04/2018 © By signing this backgowtest report and checking this box, I hereby certify that I am familiarwith 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 2 of 2