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Home My WebLink AboutParkwood VII Backflow Jan 20195yc±ams Service � � ?729 N �St1,TNC;'PUN AVF" I�CI.)S�NAPOLIS, S�I 462.1f3--3322 �' '�� J17/542-1E300 '1'�ch # = 01PF�12H9�0 Sa.l.es Tax -= 7. 00 0 1�ARICW00� C�20f�SSNG INVPS'LOIZS c/o sce r�Arv�aGrmr�vT, r,r�c 600 P 961H ST ST13 9�50 "r�rnTz�NaPoi�IS. IN �i6240 50�299f46 PAI2TCCa001� VII z�o r ��r s�r CNDIANAPOL�IS, 71V Total Labor H (7)lTRtdL7Ilfs` #199751.(3/a"1�ISP12 R�i) £'107768(6"�2T5ER RM) (CT1IlENS WATL�R� N];W SWI'.CCH 13C�Akt1� £31a�18E36 'i'0 GAi�L FOFt SERVICE CONTACT: I�'"�.�Ic,"i�"�.�'�`z=1014 I �.. _iv. +��iR^r�?� [�rt<�r= du�.COM i'sMAIL R�.FOR1'ES 'CO L�7Sfi LUC[�� C� ' It�newa7. 09/30/2019 -�'�='�7=��"�'" 0 � 7.0 PO -- :7AYQUl�RY T3ACICN7=�OW �'TlEV�NT(�R S��?V At�nual Pohai lo qrrived Service Zone porfal Trevel Hra . TypeofSys�em Manufaclurer '�rouble Call D� ouline Inspectian Pmblems Found . �`� l� <=�c.c�, �-.�� LYc�o,n ar�o� , �AM �Q.LIi �L�$�1L�-�N` �� NeaL.r ��2. of Work CompanyName Last Service DatE Qty. � �� f �� — �°� � � Material rotal Forward � �� f ��- � `�� 7he ahove Inspec�lon is made for the purpose of checkmg the mechamcal andbr elecincal operation of ihe equipment and not to� determine or guarantee proper capacity, engineering or original insiallation. Vendor shall not be responsible for the improper operation of any inspected equipment lhat, after serviceman has IeN premises, has been discharged, vandalized, tampered wi�h or damaged. The reverse of Ihis agreemeni is incorporeted herein. Pleasa read carefully. We are not an insurec Our maximum liability is limiled to $250.00. User acknowledges receipf of copy and fhat he has read and understands reverse side of agreement. C t�� a�� Pi3PC�D007 ?62�0 Sub-Total PrintCustomerName CJ-�U'L V�'i �j�� .... .. KF-oiac aav, ina BILLING DEPARTMENT Used (Each ,.. IAmount 'Date ITechnician IHrs. IRale ILaborCharge �; "1,, � �� , ,e� "� �ACKFLOW D�VICE TESTi �` State Fo� b5766 (2-15) +y £ INOIANAf7EPARTMENTOFENVIftONMENTALMANAGEMENT THIS FORMISTD BECONlPI.ETF_[O BYANINpIANA CE'RT/�'lE'p I3ACfCPLOINT�57ER. n e 9^ o e. 1. Customer name � 2: Custotner coriipatty Pfm�wa�t� �saio�6 �vesTo�s: �+reXwoon v� 3. Custorr � 4. Location of device (andadd�essffdifferentfrom cusfomerJ 5, Is the device a new assemb�y? Q Yes �No S2� iL(Y1 Re tacin serial number; 6.Type of service � 7..7ype of assembly ❑ Domestic � Pire ❑ Irrigation [] aP �DC ❑ pVB j] SVB ❑ Air Gap [] AVB 8. Typa of profection 9. Serial number of device '' � d e [] Isolation � Containment � D"7 "1 Siza�deviGe 11.Man�ufa�t�yrero�'device �Z��DOO f ❑ � Additional information (opfional) f� �IYS') ChRCK�A��S (I�A.L�S (zh�i�t) Initial �a�E fmMddW): C1 FASS ,� FAIL Finaf Dafe �mmidcyy�: _ Time: _ ❑ PASs ❑ EAIL afR GAp Neld at � PSIp ❑ Closed Tigh# �[] Leaked Held at � PSID ❑ �Closed Tight ❑ Leaked overtlow rim : Check Vaive #2 Pressure �ifferenfial q� �nlet Relief Valve Held af _. PSID Opened at_ Opened at _ PSID PSIp ❑ Clased Tight , Q Did Not Open ❑ Leaked [] Did Not Open Check Valve Held _ PSID Held at _ PSIp Opened af _ Opened at� PSIp Ps�p pid Not O en ❑ Closed Tight ❑ P ❑ Leaked ❑ Aid Not Open Check Valve Held _ pSl� ' AVB 3upply size diamefer: __ Opened fully? ❑ Yes ❑ No Companyname lnffial �g_ Telephone r Tesfer �l '�� °--J '� " � v __[ ` ' ' D lJ" (t.L `y LS . 22. Name and e-mail address oftesfer 23. Gompany name oftester (if applicable) Finaf 24. Telephonerum6er 25. Signature and registration number oftester Tester 26. Testing equipmenf serial num6er 27. Testing equipmenf calibration dafe (mm/dd/yy) ysfgning fhis backFlowiesf reporEand checlflng fihis boX, I hereby cer6iytha#I am familiarwiffi fhe infottnafton confiained in his form and #hai Yo fhe besf of my knowtedge and 6eliei, such informafton is frue, complefe and aecurate at the fime ofthe iest. � Page2of2 . ' �i', �3�' ' "� , �, � �ACKFI.qifl( D�NICE TESi fn` State Fo� 55708 (2-0� ' +' INOIANilOEPAR7MENTOFENVIRONMENTAIMANAGEMEN7 THB FORMIS 70 BE COMPLETEO BYANINp1ANA CERTlFfED SACKPLOYY7ESTk'R. e - a- a a 1. Cusfomer name 2. Customer compeny Pf�-Rku�nc�0 C'C�sSIoJ G'1 ls� �z;�TOQs r-'�tRK,�r�dD 3, Customer address (numberand streef, city, sfafe, andZ1P co e) 28C) 6 qCnr" 1Ni�ifhutbn��.0 iru �(�2u0 ` from 6.Type of service � j] Domestie 8. Type of protection [] Isolation 10. Size ofi3evice Check Valve #2 Heidatn' • PSID V � Cbsed Tight Q Leaked Yes � �] Fire ❑]frigation ❑ RP �] �C ❑ pV8 ❑ SVB [j Air Gap [] AVB 9. Serial number of device '' � containment � �j � 2 y ) � Vlapu��r� ofdevice 12. Model num6erofdevice w 0o"irn2[�-r Check Valve #1 Inifial f� Date �mMd�yr1: � Zb !°� Held at �_"� P51p Time: iD; DU � Ciased Tighf ]4�PA55 ❑ Lealced ❑ FAIL . Final Date �m„�cmyy�: u Held at PSID Time: ❑ Cfosed Tight ❑ PA55 [] Leaked ❑ Fli1L �[R GAP ��asured vertical inches above overtlow rim : fnftial Tesfer name offester 22. Name and e-mail address oftester 23. Company name oftester (if applicable) Final 24. Telephone�umber 25. Signature and registrafion number oftester Tester 26. Testing equipmenf serial number 27. Tesfing equipmenf calibrafion dafe (mm/dd/yy) ysigning fhis bacicFlowtesEreportand checlflng ihis 6oX, [ Bereby certifyfhatl am familiarv,rith tha infotmafion contained in his fnrm and tha# fo fhe 6esf of my knowledge and helief, such informafton is frue, complefe and accu�ate at fhe fime oifhe i'esfi. . � Page 2 of 2 . a Pressure bifferential p,� �nlet Relief Valve Opened at _ oPened at _ p51D pSip , [� Qid Not Open ❑ Did Not Open Check Valve Held _ PSID Held at_ PSt� Opened at_ Opened at_ PSID PSIp ❑ Closed Tight ❑ Did Not Open ❑ Lealced ❑ Did Not Open Check Valve He(d _ pSiD � l� Archon - Citizens Utilities; Indianapolis Backflow Prevention Assembly Test and Maintenance Report Customer Information Name CITIZENS ENERGY GROUP WATER CUSTC Contact Address 280 E 96TH ST INDIANAPOLIS, IN 46240 Residentiai [ ] Non-Residential [ ] Assembly Test Report Initial Test Check Valve #1� [ ] Closed Tight [x] Leaked �. �� , ,., , �,� � �. , � ., Assembly Information Type DC Size 4 Manufacturer Ames Location FIRE SPKR ROOM HazardlD 3771279 Check Valve #2 [ ] Closed Tight (x] Leaked Model 2000SS Serial# 107768 Hazard FireProteciion Testerinformation The backFlow preveMion assomblydelailed on fhis fotm has been tested and mainlained as requlred by codes and regulalions, is cehified to be We & accurele, and Is opereling wilhin accep�able parameters al Ilme of �esting. ' Only Manu(acWret's replacement parls have boen used. "Test records mus� be keptfora minimum of �hree years Tester Name Tester License Expiration Certification # Test Kit Mfr & Mod # Serial # Company Address Phone Gerald Glover- Koorsen Fire & Security Indianapolis BF18-6331 Midwest 835 07080771 Koorsen Fire & Security Indianapolis 2719 N Adington Ave Indianapolis, IN 46218- (317) 542-1 S00 FAIL Test Date: 01/26l2019 Date Submitted: Awaiting Payment Repairs and Notes: First check failed and needs rebuilt Archon - Citizens Utilities; Indianapolis Backflow Prevention Assembly Test and Maintenance Report Customer Information Name CITIZENS ENERGY GROUP WATER CUSTC Contact Address 280 E 96TH ST INDIANAPOLIS, IN 46240 Residential [ ] Non-Residential [ ] Assembly Test Report Check Valve #1 2.4 [x] Closed Tight [ ] Leaked Repairs and Notes: � �� . , �� . , * �� , Assembly Information Type DC Size 0.75 Manufacturer Watts Location RISER RM HazardlD 3771278 Check Valve #2 2.4 [x] Closed Tight [ ] Leaked Model 007M2QT Serial# 199251 Hazard FireProtection Tester Information The backFlow praven�ion assemblydeiailed on �hls form has been tes�ed and main�ained as required by wdes and regulations, is cetlified [o be Ime & acwra[e, and is operating wilhin acceplableparametersa[limeof�es�ing. 'OnlyManufacWrefsreplacemenlpahshavebeenused� "TestrewMsmus�bekeplforaminimumofthreayears Tester Name Tester License Expiration Certification # Test Kit Mfr & Mod # Serial # Company Address Phone Gerald Glover - Koorsen Fire & Security Indianapolis BF18-6331 Midwest 835 07080771 Koorsen Fire & Security Indianapolis 2719 N Arlington Ave Indianapolis, IN 46218- (317) 542-1 S00 PASS TestDate: 01@6@019 Date Submitted: Awaiting Payment