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Home My WebLink AboutParkwood VII Backflow Part 2 Jan 2019Sysf.errisService Z71g N 11;�L:CNGTON AVL ° � Ii�TL)TANAPOLIS, TN 46218—:3372 317/542--1H00 FI ITY N25 'PecYa # = 01PAR8900 £yt11�5 T�x = 7.00� •• �•e - :>Q3299647 6 INVOICE TO: SERVICE LOCATION� l?A1.2I{WO011 CROSSSNG INVI3STORS PP.RTCW()(5n VT� PF3PG7D007 ' C/0 :,CP MANAGEM�NT, LLC 280 1? 96TH Sm Ei00 � 9(iTII ST aTL '150 7:ND:CI�N7aPOl.�tiS, IN 46240 INDTANAPOLIS, 7N 462A0 (3)DOM�STIC ;�`934451(1.�i"P�I�TTfOUSP) #t98089�(2"RIS�� RM) �t9S0890(2."L2TSLi� ItMj NFW SW7'PCFi 130ALZll £3�.9-1.886 TO C�1T�L FO}� SLRVTC�' CON'T'I�,C'.1': TI-IT.D 317-53£3--5G1.� TC'..�: r .ls ' ��"— . _ '. ': " •>" '�:•�. (CT'I'IZliNS WATk�R) EMAI1�� U1.?.0 P� = S't�i��eiva]. 09/30/1019 ��'' �QnQ. Faz�_ J�aNUAkY �ACI{'L^'LOW P'x`i&V�;Id�1^Oi� SLRV Ai�nrla]. Service Zone �o Arrived Depatled Pmblems Fovnd: ... _... .._, .._..... .__ .>._. ..., . . ..... ........ ._........ — t�o�s�nc i n '�e�o�s¢� .�t- �3tius r F�1� �� Rx,i�e-f (en�iny , TypeofSystem Manufacturer �-. � Trouble Call �i �Routine Inspection Descriplion of Wark Pertarmed: �] S'��S-t u, rrl i n � S en�� . a �, CompanyName Last Service Date Qty. I Material Usetl � � F� U � , Date �Technlcian � -�ma[enai��oca�rorwarui . �� — Tha above inspectlon is made for the purpose of checking the mechanicai andlor electrical operation of tha eqwpment and not to determine or guarantee proper capacily, engineering or oriqinal installation. Vendor shall not be responsible for the improper operalion of any inspected equipment that, after serviceman has left premises, has been discharged, vandalized, tampered with or damaged. The reverse of �his agreement is incorporated herein. Please read carefully. We are not an insurer. Our maximum Ilability is limited to $250.00. User acknowledges receipt of copy and that he has read and unde�ands reverse side of agreement. Customer' �gnature F <��- � < Print Customer Name . �. �v e.. Total Labor Hrs. Sub-Total KF-018C Rev. 1/13 BILLING DEPARTMENT �: �� •,'��. f%' �� AC6CFl.QW D�VIC� TEsi �A�� steteF'armss7ae(z-a5� � . . IN�IANA OEPAR7MENT OF ENVIRONMENTAL MANAGEMENT T/i1S FORMIS TO.Q� COMPI,.ETF_L7 ByqN/NAlANA CE'12TG�'16p BACKFLOW TESTER. . o • , e.�- a , a. . ustomke�a�m'� � � 2.Ctys tnercorripany ��P-z�>5, n'� .y c�Jee�p� S �Q.r�c.i,Jdo 1J l 1 3. Cus omer address (n� berand s t, olty, state, and ZlPcode � �� s�- ,�.,,z a�.�,�` � ,�� ?'f � � )solation �j�-V.1'b (� ❑ Fire ❑ Irrigafion ;,JS Inifial Dafe �mmidNy�; `_�`'�� Time: D�b / ASS ❑ EAIL . Final Dafe �m„✓dd�yy�: ,_ Time: ❑ PASS ❑ FAIL Heid t�`� PSip �Iosed Tight ❑ Leal<ed Held af,_ PSID ❑ Closed Tight [j Leaked � � Check Vaive #2 Held at _ pSID �Closed Tight [jLeaked Heid at _____ pg(D ❑ Closed Tight ❑ Leaked a Yes a q oc ❑ Pvs L7 sva [( Air Gap p nve �er of ewce � ' � Pressure Air Inle} Opened ai" �� Opened at,_ p51D PSip , [� Qid Not Open ❑ 1]id Nof Open Check Valve Held _ PSII7 Opened at_ Opened at_ PS1D PSIp Q Did Not Open ❑ Aid Not Open Check Valve Held _ PSID , Yes Initial 7esfer 22. Name Final 24. Telept Tesfer 25. 27. 17. Company name name dafe g fhis backflowtestreportand checldng ihis boX, l hereby cerfifyfha{ � am familiar�nrifh fhe infottnafion contained in and fhat to the 6esf of my knowledge and helief, such fnformafton Is �frue, complsfe azid accu�ate at the fime of'the test. . � Page2of2 . �: • "��, s• r �P.CtCFROW D�V►C� I ESi ��' StaleFofm55708(2-1� �j;• IN�IANAOEPARTMENTDFENVIRONMFJ`1TAlMANA�EMENT THIS FOR� IS TO B� COMPLE7EA BYAN INp�lA�NA CERTIF7EP PACKPLOINTEST�R. � � 6 ❑ F�re ❑ Irrigation ei Isolation ,� S Checi<Valve #1 Initial ��9p51P Date �mrr✓ddhv):� � Held a Time:/�a _a ��osedTight �pSS [] Leaked , ❑ FA1L . Final p51A Dafe �mrNdrurr):.--- Held at,__ Time: ___ ❑ ClosedTight ❑ PASS [] Leaked [] FAIL �AIR GAP _ . . _.._..�,,.,..,;.,, • � Chedc Valve #2 ------ Held a� PSID �Closed Tight Q Leaked a ,se��u�y ❑ oc C] pvg L7 sys ❑ Air Gap ❑ nve n6er of devLe � pressure Di$erential qlrinlet Relief Valve � �� Openedat.___.PSID Opened at �—. pSID [] Did Not Open [] Did Nof Open Check Valve Held.__ PS1D Opened at �_ PSiD Held at _____ p51D Opened at __ pSlp ❑ pid Not Open ❑ Closed Tight ❑ Leaked ❑ p�d �t Open Check Valve Held __ PSID � . A� ,.,, ��ai.,� fl Yes ❑ No name Initial � g. Telephone n Tesfer `�� ' on Tcetinrt P.tlIIL Final 1'ester of ' �23. Company name ning {his hackflow tesi reportand checlang this boX, [ hereby certity tha# 1 arn familiar witb the infioxmation confiained in rm and �fhat fo fhe besi of mY �owledge and 6elief, such infottnation is fiue, complefe and acci�rateatihe fime oithe'Yest. � Page 2 of 2 . 1'. t', BACKFL.oUV D�VIC� �'�5� " Slye Portn 65788 (2-15) ��^.+ �Np�qNppEpARTMENTOFENVIRONMENTALMANAGF,MENT 7NIS F'OR1V/!S 70 6E' CONJPL�T�P BYANINAIANA CERTIP,EO BACKFLOW TESTER. o ' }� 2. Cu u�er po��mp�any 1. C ername �\ .5�5�, yh�J�-iz[ 5 �(�CLWDc d...,,a �r�Pt r.i . state, and ZIP code) � � . . ---- _ _ � �, ,. ot„ ls the device a L'� 8. Type ot Pro�ncu�i � rl Isolation ❑ Fre p trrigation 13. Addifional informatlon �opwna,� , \ �� 1/��5 \�Gc3.'`� r� ��'c1 �id�Z�J o" Date � mmfdyyT --. Held at �_ PS1D Time: __ � Ctosed Tighi �pSS [] Leaked . - -J— Final PSID Date �mmiedhy)� .._-- Held at _____ Time:,__ �'ClosedTight ❑ PASS ❑ Leaked ❑ FAIL 15. Gomments amea (`G [nStial �B:Teleph� c�31�--�f � Tesfer ,,,,,,,,;,,,, I�7. Company name �Pt mberofieste �� ?1, Testing equipgjenf calibration dah ) C� - il� -azs 23. Company name 22. Name e-��o�� u.,.,,.,.._ _ -. Final � 24. Telephonelium6er 25. Signature and registration number of fester 7ester 27. Testing equipment cali6rafion dab 26. Testing equipment serial num6er [gning fhis 6acicflowfesirepo�tand checking ihis boX, l hereby catfiityfhatl am familiarwith iha infioxmation contained in form and #hatio the best of my knowledge and helief, such inforcnafion is frue, eomPlete and accurete atfihe time 4P 9e 2eof 2. and Check Valve #2 Held a ❑ Closed Tight ❑ Leaked V � e p oc ❑ Pva ❑ sys Q Air Gap ❑ ava n6er.ofdevice � pressure Lliiferentia! q� �nlet Relief Valve ' Opened at __ pSID Opened at__ PSID ❑ Did Not Dpen ❑ Did Nof Open Check Valve Held __ PSID Opened at�_ PS1D Held at _ PSID Open PSIp ❑ pid Not Open ❑ Closed Tight ❑ Leaked ❑ D�d Not Open Check Valve Held __ PSID � Yes