HomeMy WebLinkAboutNovo Backflow 10-23-19FIRVIGE WORK ORDER
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Marti Bu5irk
From. Carmel 8ackl'low <BackflowQa carmel.in.gov>
Sent: Friday, October 25, 2019 8.21 AM
To: Mard Busick
Subject: We have received your response for City of Carmel 8acflow Test Form
Testers Entail inaici.busickalcoorse7.eonx
eleet Tester From List SELECT IF TESTER IS NOT ON LIST
If Tester is not on t i�
drop down list please
add their infoi-rnation Noah l7 Childers
below
Indiana mite FIS 4030
Certification Number
Gauge Information 10101190
Phone Number (317) 42-1 00
alibrzd n Date 04-14- 01
Select Company or Self Company
Company Name Testing T oorsen
For
Phone Number 317) 54 -I 00
J.
Address
Street Address; 2719 N Arlington Ave
City: Indianapolis
State / Province: iN
Postal 1 Zip Code: 4618
Select Service Use
orrunercial
MANAGER NAME or
COMMERCIAL
Novo
CUSTOMER NAME
Type a question
5118486
DEVICE LOCATION
Street name, South Rangel ine Road
ADDRESS
Douse number: 12.15
City; Carmel
State; IN
Postal code: 402
oualry: United Mates
Existing, New or
Eidsting
Replacing Device
Device Serial Number
140
Manufacturer of device
Wilkins
Device Size
1.2.5
Model Number Of
75 L
Device
Type of protection
Containment
Type Of Service
Domestic
Type a question.
STOCK ROOM
Hazard Code
RP
Passed or Failed PASS
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Date
Time
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Date
Time
Testers Full lame;
Date
Time
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Marci Busick
From, Carmel Badflow <Backflo C carme1.in.gov>
Sent: Hday, October 25r 2019 8:23 AM
To: Mard Busick
Subject: We have received +our response for City of Carmel Backflow Test Form
Testers Email rnarci.busick@lcoorsen_com
Select Tester From List. SELECT IF TESTER IS NOT OIL LISP'
If Tester is not on the
drop down list please
Noah Childers
add their intonnation
below
Indiana State
EF I G4030
Cetfi cation Number
Gauge Information
10101190
Phone Number
317) 54 -1800
Calibration Date
04-14-2.019
Select Company or Self
Company
Company Name Testing
I
For
.00rsen
Phone Number (31' 54 -1800
i
Street Address; 2719 N AI-lington Ave
City; Iidianapolis
State / Provitxce; W
Postal 1 Zip Code: 4621
Select Service Use
Commercial
MANAGER NAME or
COMMERCIAL
Novo
CUSTOMER NAME
Type a question
N/A
DEVICE LOCATION
Street naine; ,South Rangeline Toad
ADDRESS
House number: 12 15
City: Carmel
State; IN
Postal code; 46032
Countiy. United tatt s
Existing, New or
Existing
Replacing Device
Device Serial Number
2LK1143
Manufacturer of device
Ames
Device Size
4
Model Number Of
Device
2.00OSS
Type of protection
conblinn ent
Type Of Service
Fire
Type a question
STOCK ROOM
Haaa W Code
DC
Passed or Failed
PASS
DC
1 DC .
Cah& Valrrifl 13r1:: _ki WILM NND
C1oaeMl'I'iq�1#
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Clock Valve #3 Held Al what PTSD
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Date
Time
DC
DC k
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Cto&m Tkght No
2
Date
Time
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Device Tagged
Device Notes
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Date
Time
PVE
Date
Time
PVB
a
;LealceJ YES
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10/24/2019 9,00 A
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Yes
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RP
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Time
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Date
Time
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Marci Busick
From: Cafinel Backflow <Backflow carmei,in.gov>
Sent: Friday, October 25, 2019 8:25 AM
To: Mard Busick
Subject: We have received your response for City of Carmel Backflow Test Form
Testex^s Email mwci. busi ck@koorsen. coin
Select Tester From List SELECT IF TESTED IS NOT ON LIST
If Tester is not on the
drop down list please Noah Childers
add their information
below
Indiana State
BF18 4030
Certification Number
—
Gauge Edorination
101011 0
Phone Number
(317) 42-1 00
Calibration Date
04-14-2019
Select Company or Self
Company
Company Marne T lb g
I oorsen
For
Phone Number (317) 542-1800
i
Address
Street Address: 2719 N Arlington Ave
City; Indianapolis
State I Province: 1N
Postat 1 Zip Code: 462 18
SeIect Service Use
Commercial
MANAGER NAME or
COMMERCIAL
Novo
CUSTOMER NAME
Type a question
NIA
DEVICE LOCATION
Sti et name: South Range,11ne Road
ADDRESS
House number: 121
City; Carmel
State: IN
Postal code; 4603
Country: United States
Existin& New or
Existing
Replacing Device
Reason For Replacing,
Removing And/or Other
DEVICE IS NOT IN USE
Additional Information
Device Serial Nwiabtr
3088873
Manufacturer of device
Wilkins
Device Size
1,5
Model Number Of
Device
75
Type of protrCtion
Containnimt
Type Of SeMce
T(Tigation
Type a question
BACK ROOM
Hazard Code
R'
Passed oi' Failed
PASS
DC
oc
Ckeek Valve 41 ReM At Vnw PIED
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I.ealy d
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CINW light
Ixaked
Date
Time
2
DC
Date
Time
P
Date
Time
RP
Massed or Failed
Tagged
Date
Time
Notes
PB
Date
Cheek Vaivc NJ Iletd A I What P18b
j Clamed' 1&bt
I .
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CLeek V:d% a 02 112W M WIMI PM
RP i
Clwck Vatre 91 Held At ► hat PisD �
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RP
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x3Jd NO'f CVen
FAIL
YES
10/24/2019 9:00 AM
DEVICE IS NOT W USE
r. F
opened At What PSID
Did NOT Open
Rw OPEN
Cued![ Valye JIM At What HID I
3
Time
PVB
Date
Time
AIR GAP ONLY Final
Test Results
Date
Time
Testers Full Name;
Date
'rime
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Nd OPEN
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marci.lawsic1 ��Coorsen.corn
10/25/2019 8,20 AM
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