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Home My WebLink AboutC106 Backflows 9.26.19 (Irish)1 BACKFLOW DEVICE TEST state Form 55788 (2-15) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Th7S FORM IS TO BE COMPLETED BY AN INDIANA CERTIFIED BACKFLOW TESTER. company 3. GUlitO d ,(nur r)d sheet city, state, and ZIP code) h ^n 4. Location of d (and address if different them customer) 5. Is the device a new assembly? ❑ Yes No t e t Replacing serial number. 6.Type of service 7. Type of assembly 'Domestic ❑ Fire ❑ Irrigation RP ❑ OC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB 8. Type oEsoletlon ❑ Containment otection 9. Serial number of device .V 7,)n r7r Initial Date t,yt:�sb I Time: .(PASS ❑ FAIL Final Date p�,.unyyi: Time: ❑ PASS ❑ FAIL vertical inches 16. Initial Teeter Final Taster Check Valve #1 Held at ,� PSID ❑ Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked Check Valve #2 Held at _ PSID Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked size diameter. Pressure Differential Opened at -�) � u PSID ❑ Did Not Open Opened at PSID ❑ Did Not Open Air Inlet Opened at_ PSID [IDid Not Open Check Valve Held PSID Opened at _ PSID ❑ Did Not Open Check Valve Held PSID date ❑ By signing this backflow teat report and checking this box, I hereby certify that I am familiar with the information contained in this torn and that to the begot my knowledge and belief, such Information Is true, complete and accurate at the time of the test Page 2 of 2 BACKFLOW DEVICE TEST State Fa 55768 (2-15) INDLINA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT THIS FORM IS TO BE COMPLETED BYAN INDIANA CERTIFIED SACKFLOW TESTER. 16. rA ,&rDomesUc ❑ Fire ❑ Irngatlon of rotection FIsolatlon ❑ Containment of 4sy" II 111. Mainufacfyrer of devige Date (awaari)% Time: PASS ❑ FAIL Final Date paeawtyY Time: ❑ PASS ❑ FAIL AIR GAP Measured vertical in Final Taster Check Valve #1 Held at 7SPSID ❑ Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked rim inx=awunumrtg.� 2. Customer company a new URP ❑ DC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB 9. Serial nu—"— ^f device 12. Model number of Check Valve #2 Held at _ PSID Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked size Opened atc� d PSID ❑ Did Not Open Opened at _ PSID ❑ Did Not Open Air !n%', Opened at_ PSID ❑ Did Not Open Check Valve Held _ PSID Opened at _ PSID ❑ Did Not Open Check Valve Hek1 PSID name Yes F-1 No ❑ 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 2 of 2 rrAl BACKFLOW DEVICE TEST DIAD Fam 5579a " MEN INNA DEPARTMENT OF ENVIRONMENTqJ MANAGEMENT THIS FORM IS TO BE COMPLETED BY AN INDIANA CERTIFIED BACKFLOW TESTER. name company a. Location or derViCepw address lfdioererrf from customer) 5. Is the device a new assembly? U Yes D!rM j L Im c h i Replacing serial number. S.Type of service 7. Type of assembly obomestic ❑ Fire ❑ Irrigation �'Rp ❑ DC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB 8. Type of rotection 9. Serial number of device / UIsolation El Containment 7 Y 7, i,09 _3 I Date PASS ❑ FAIL Final Date 1m.wam: Time: ❑ PASS ❑ FAIL AIR Initial 18. Tef Tester _ 317- Final Tester Check Valve #1 Held at PSID ❑ Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked rim: number 12. RP Check Valve 92 Held at PSID El'Closed Tight ❑ Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked L PVBISVB ressure Differential Air Inlet Relief Valve Opened at � - Opened at PSID PSID ❑ Did Not Open ❑ Did Not Open Check Valve Held PSID Opened at _ Opened at _ PSID PSID ❑ Did Not Open ❑ Did Not Open Check Valve Held PSID AVB ❑ By signing this backflow test report and checking this box, I hereby certify that I am familiar with On 1. f inatlon contained In this torn 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 BACKFLOW DEVICE TEST I State FW 55788(2-15) �/ ` INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT THIS FORM IS TO BE COMPLETED BY AN INDIANA CERTIFIED SACKFLO W TESTER - Customer 1. Customer name 2. Customer company NhcrS 3. Custorr�y�Il1d (n and skeet, Guy, state, and ZIP code) )U(D ono 4. Location of day (and address,IN�different from customer) 5. Is the device a new assembly? ❑ Yes No C ✓ C h I Replacing serial number. 6.Type of service 7. Type of assembly ❑ Domestic ❑ Irrigation ❑ RP ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB 8. Type of protection 9. Serial number of device 9 r2 0 O alsolation ❑ Containment oC C JG 10. SIZa ev�r)e 11. Manufa rbr o 12. Model number of device OQ c s 13. Additional Information (optional) RP "I DC PVB/SVB Check Valve #1 Check Valve #2 Pressure Differential Air Inlet Relief Valve Initial Cate rn,nvurr�ijr'b I' Had at PSID Held at 0 PSID Opened at Opened at_ PSID Time: _ '[$PASS ❑ Closed Tight ❑ Closed Tight PSID ❑ Did Not Open ❑ Leaked ❑ Leaked ❑ Did Not Open El FAIL Check Valve Held _PSID Final Date ram+✓aa m: _ Held at _ PSID Held at PSID Opened at_ fined at PSID Time: _ ❑Closed Tighl ❑Closed Tight PSID ❑ Did Not Open ❑ PASS ❑ Leaked ❑ Leaked ❑ Did Not Open [I FAIL Check Valve Held _PSID AIR GAP AVB Measured vertical inches above overflow rim: S size diameter. O ened fully? ❑ Yes ❑ No 15. Comments Tester Information 16. Name and e-mail address of teeter 17. spa q d tester (Aapplicable) Tony Royer troyer@iris imechanicalservices.com Iriish Instal Meycantcal Services 18. Telephone number 19. S'nature and rogiaVation number of tester T~ 317-294-9875 9-95-0963 20.T=Jp7t.SWAL,)y U.Yn 2 21. Testing equipment callbratlgq 1 noer—i;✓-ivi8 / da a mnY ) 22. Name and e-mail address of tester 23. Company name of tester (H applicable) Final 24. Telephone number 25. Signabre and regiatratlon tester Taster IL.CG 26. Testing equipment serial number 27. Tasling equipment calibration date (miWddyy) ❑ By signing this backffow lest report and checking this box, I hereby certify that I am familiar with the Information contained in this forth and that to the beat of my knowledge and belief, such Information Is true, complete and accurate at the time of the test - Page 2 of 2 BACKFLOW DEVICE TEST Stele Ft>.m 55798 (2-15) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGE IT THIS FORM IS TO BE COMPLETED BYAN INDIANA CERTIFIED BACKFLOW TESTER. name 2. Customsmer company a. Location of aeV (elra adtl/eS3 offerent thorn customer) 5. Is the device a new assembly? LJ Yes .L':INo X-C LH Replacing serial number. B.Type of service 7. Type of assembly ❑ Domestic OFire ❑ Irrigation ❑ RP tirDC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB -$CPASS ❑ FAIL Final Date runs Time: ❑ PASS ❑ FAIL AIR GAP Measured veNcal Initial TOSW Final Taster Check Valve #1 Held at 3 10 PSID ❑ Closed Tight ❑ Leaked Held at PSID ❑ Closed Tight ❑ Leaked Check Vahre#2 Held al � . D ❑ Closed Tight ❑ Leaked Held at PSID ❑ Closed Tight ❑ Leaked size Relief Valve I Air Inlet Opened atOpened at_ PSID PSID_ ❑ Did Not Open ❑ Did Not Open Check Valve Held _ PSID Opened at Opened at _ PSID PSID ❑ Did Not Open ❑ Did Not Open Check Valve Held PSID name Yes ❑ 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 2 of 2