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Home My WebLink AboutBackFlow ReportsSystems Service , � , � i�1 � ,� 0,� ,� � i „ ��, ry , , 3 � � / ��, ; i �i�J �� i� � �� ,r(r 1..,.; l ; i;:17 ,' ... QI.F...�,_OU 13if > t�.� - �i�C�"e, E TO: � .i. � �U�ii i (() 1 �; i 1 �].'( ... (��(, ,� � .1 ��ilil�l � lu lf'.i' � L�.; C.�.�i _ � I l5 a. � ��1� j�l �I�)J�T':� . �).�.�iJ� Z�� 1..� .,v,>.� ;�,;; ;E LOCATION: i •; f:, , , i ;I� t� V� J i � V 1 A 1 �+ 1� _ ��i> . .)� `i.�i�i)�� rJ � . ( ,_ . .�. <�� if� �i"1 �,'IJ� ii "?f� `�i� i� �.i. �l �.�)I ��, 1t � '��i Ulj � �L ;l_� Ui_i� �) itr�i 1I� ��.i iJ i.l_ �� , i ��) t.\.. �� . J� i�. � ) xl. I: ( �I.. �i..�;� I. I i':i.�i �'( t'n71tr ,C�`�i 1 I ��i'� P C, �� L' '` _ _ �i ,T .' i� _A. _.. ... . _ . . u�,. .. �� i .� � S', i. J � i ,1 . l ��. , 1 u i_ 1� f� I �il � (1 _ � , i 1 i � l,[�,i `rC.l � lN i;>, � t� '(`, � , J.i?r �` i i�r :.... Potlalto Service Zone Portal Travel Hrs. Arnved .. Departed TypeofSyslem Manufacfurer � n { . ❑ TmubleCail � 1 1�( � tip_ �Routlne Inspection l Pmblems Found . n% a \�Q�`�S`� . � 21Z; ��i-.; �s-� `�Ge (� [-' (U..� 4.sa � 'i-'cI11.fL C3� (LI ( �ZG7�`.�` r�' .. Q I �; '_'^i'.\tL(in� ��:TTni k"cJ .. ��% U/`PG'G� G(rG p1Dt �i � �� Oescrip�ion of Work Pedormed: ../"��Ow/, S}..STGIi-^ .. UU(P/vL-��\ GL. U��...�T�J�'� .� .. . . .. .. I Company Name Last Service Date Material Used 'j �� % (�� The above �inspection is made for the purpose of checking �ha mechanical andlor determine or guaraniea proper capacity, engineerin9 or original insiallation. Date operaiion of the Technician and no�to Vendor shall not be responsible for the improper operalion of any inspected equipmenl ihat, after serviceman has IeH premises, has been discharged, vandalized, tampared with or damaged. The reverse of ihis agreement is incorporeted herein. Please read carefully. We are not an insurer. Our maximum liabiliry is limited to $250.00. User acknowledges receipt of copy and that he has read and underetantls reverse side of agreement. Customer's Signature F X �.�, �; �_ Dale Rale Totai Labor Hrs Total : MateriaL Su6-Tota� Print Customer Name ,.� ,,, o� o,,., , �,z s� r,, � ; � e�,cxF�.ouu d�v'c� r�sr • , � S�ata Fa�b518B (2-7b) +y�N; IND�ANADEpARTMENTOFENVIRONMEN7ALMANAGEMENT 7HIS FORM iS TO B.E COMP[.ETED HYAN INDIANA CPf2TIFl6P BACKPLOW TE57ER. o ^ . ..B- - o . v. . 1. Customername p 2. Customercompany ��w�� Qr(Gwood �jC , x 3. Customer address (num6erand street, cify, sfate, and ZlP codeJ � 00 C— �T'y s-t� 2...d� ot:s= �� lGZ�+o 4, Location of device (and addressifdifferen,t from cusfomer) 5. Is the device a new assembiv? � I-1 Yes o 1�� IZ�^°— Re lac: 6.Type ofservice 7. Typa oi ❑ Domestic � ire ❑ lrrigation [] RP 8. Type of profectton . 9. Sedal r ❑ Isolation Gontainment 10. Size of deYjce 11. Manufacturer of device 12. Model G AmtS �I3, Additional information (optionalJ c�� ! d;d��t G,ol�! � Check Valve #1 Initial Data [mMddyy):5� Heid at ^ PSID Time: ❑ Ci Tight � P�y�'s eaked � FAIL Final Dafe �rr�,✓dcyy�: u Held at_ PSID Time: ❑�Cfosed Tight ❑ PASS [] �aked ❑ PAIL AIR GAP M�asured vertical i�ches a6ove overflow rim : e-mail Initial 7esfer 22. Name and e-mail address of fiinal 24. Telephone number 26. Tesfer 26. Testing equipment serial nurr Check Valve #2 Held af3• � PSID Glosed Tight ❑ Lealced Held at _ PSIa ❑ Closed Tight ❑ Lealced size diameter: rG sting "'e — and registration number o 27. Testing q pve ❑ sva ❑ nir �ap ❑ ava :vice �..�... Pressure Differential I - o;,,:,,F.._,.._ Airinlef Opened at_ Opened at_ P51❑ PS�� [j �id Not Open ❑ bid Nof Open Check Valve Held _ PSIp Opened af _, Opened at_ PSIA PSIp ❑ Did Not Open ❑ Did Not Open Check Vaive Held PSID AIIs Opened fuliv? I l Yes I-1 No 17. name of b calibration date (mm/ddyy) ompany name oftester (ff a [] Bysigning fhis 6ackflowfesireporE and checldng fhis box, i herehy cer6iyfhat I am iamilfarwifh fhe ihformation confained i� fhis form and fhaE to the 6est of my knowledge and belief, such info�tnafion is ftue, complefe and accuraf� at the fime offhe test • Paga 2 of 2 � Systems Service ; 1 � ,�, ��, � i� �� - 1� , i ,, „1, , _ �� s I,' ..e -�U�� O i 'P.�.ii:1�lO!) W �lA � ,��7� ,> i.'�.. - � i �.. .(�i 1 � (i ' ; � i ;'I:�i'i.�_ l.�`% �� i� i�,lr� i j`.f.'� ),L�; bC'0 �" "(,`I_i. ,.1' ,'�'_, � 0 � u I 7UL�-`e��1 (i)a�Iu� 11l�...... � 'y�... .. �::i.�'.��) lll. ,,�,`�='(il 1s3� it .._ _ ., . � ,�s � � �. � � �j I ` ' - `3 � � � �l�i i i, l '�_ � ' � � J 1 �ii ilVIC I ,131 1 � . 11 'i i J I I(, 1 C e �A) � j� I<i �� I i� ro( � l�t � i , r r.�r � � i�,�� 'lll - , ,� ", Clt.A � ''S I �( �''� _ . .� � vi_9 . . A \ ._ 1 �. l � . .1 A � � ( � I 1 � �(� 'l) i } ,s ,2�i i �37�.� [C " t>i�i p�. . � ,�'�I`(� . P.V '.r _ rortai�u Arnvetl Service Zone Poriai Travel Hrs . . 7ype of System ManufacW�ar . ' � T�le Call i 3a��ow ;� Roulinelnspection �escriplion of Wark PeAormed: $� ZoR 1-Gg`� -, fasr, � 1i�9'7z39-- F.4T� Company Name Last Service Date Mateflal Used �� ( ._,�� }',UU: °� ••. >G; ,�,��;GL SERVICE LOCATION: � . .� '�: .,. '1..� - �vU � iGl� �.I: Amou�t i3ii� � ..,.iu,i ,Ti i, :� � — `� �J 4 L, � � �� , ,.,, �.,...,. ProblemsPountl: QvO�e� .. � 2��,�f va�,� d;d .,at oP� _ � I'��1�z3`f Dale �Technician ;MaterialTotel�:Forwam �-�. �� The above inspection is made ior fhe purpose of checking the mechanical andlor eledrical operetion of fM1e equipment and not lo datermine or guarantee proper capacity, engineering or original instailation. Vendor shall not be responsible for the improper operalion of any inspected equipment that, aNer serviceman has left premises, has been discharged, vandalized, fampered with or damaged. 1 mited tor$250 00. User acknowledgers�ecelpt ofrcopy and that he has read and understands revers�e side olf agrelement. fs . . _ . _. ._..__ Date CustomePs.Signalure ` X f � � '�i (t16ci nn.� Totai Labor Hrs. Sub-Total PrintCustomerName �../�( � �,�"' -� -��' ��"�� KF-o�ac Rev. ut3 � � �� BILLING DEPARTMENT wM� �a33oZG3 � �, � . , da �ACKFL.OVtI D�!/6G� TEST' ° , � Sfate Farm 657a6 (&15) i '� INDIANAOEPARTMENTOFENVIRONMENTAIMANA6EMENT 7HIS F'OF2M7570 BE COMPLETED BYAN INPlAAIA CBf2TlFlEO 8,4CfCFl.DVYTESTER. � o e.11- v o. 1. Customername. �j � � 2. CustomePcompany p 1 q�^ woo �}� 3. Customer address (num6erand stree#, cify, state, goo � 4 ��`` 4. Location of device (and address i� ereqf fmm c �� W w`' Check Valve #2 � 6.Type of sery 7. Type o embly Oomestic ❑ Fire ❑ lrrigation P [] DC [j PVB j] SVB ❑ Air Gap ❑ AVB 8. Type of protection . 9. Serial number of devic'� r y�,7.239 ❑ Isolation Containmenf ��'"'" - � 10. Size of device 11. Manufactur r of device 12. Made) numher of device l. S " l.✓� �,(c.;�,.r �17SkL 13, Additianal information (optional) 2ef;t� vat�a ct�d .tio.t nraer- - �R�'t_ Initial Date �r,�rr✓adrry):S 30 l Time: _ ❑ PLN"�' AIL Pinal DflYe (mMdayy):,,_ Time: _ ❑ PASS ❑ FAtL AIR GAP M�asured vertical inc In3tia! �8 ?ester 20. 22. fiinat 24. Tester 26. Checl<Valve #1 Held at�_.�PSID Closed Tight ❑ Leaked Held at,_ PSID ❑�Closed Tight [] Leaked a6ove and nd e-mail a nenumber equipment 79. Held at _ PStD Iased Tight [] Leaked Held at _ PSID ❑ Closed Tight ❑ Leaked • =N 4sz4o a new assembiy? L] Yes Pressure Differential' Air Inlet Opened at_ Opened at_ P51� PSI ❑ Did Not Open id Nof Open Check Valve Held _ PSID Opened at_ Opened at ____ PSID Ps�p [] Did Not Open ❑ Did Not Open Check Valve Held _ PSID name offester `�'j' �'4�lgG 1. Tesfing equipmenf calibraiion daf� G(�3 - i R 23. Gompany name number of tester 7. Testing equlpment cali6ration dat� (�Fapplica6leJ ❑ Bysfgning fhis hacicf(owtestreporE and checlang this box, l here6y certiiy that I am fiamiliat�wifh ihe informafion confained in ihis form and thaf fo the Hesf of my Knowledge and betief, such infor�nation is true, complefe and accmafe ai the time oithe test Page 2 of 2 WM� Go�30z55 6 ±F p-�q(s �(p�y y��{�C�/pCy� y � • �/ 1��9VY\H-R�otlY ll{.tlACC+ 1��1 Y� � G�` State Fupn 55788 (2-05) +� nj6 aa IN�IANA�EPARTMEN70FENV�RONMEN7ALMANAGEMENT THlS FDRM IS 70 B�' COMI'LETED BYAN INDJAIVA C6RT(Fl�P 6ACKFLQYYT.ESTER. " o - a:I!- - o , o. 1. Cus{omer name 2. Customer company �4�l��,,.vod �'k Par��.✓oad LrX 3. Customer addtess (numberand strsef, city, sNate, and ZIP code) 0 p � rw .F. 2,,. c� � a.,... o t; s. 27J '-f 6 240 a.�nnafionofdevice(andaddressifdiffereqtfromcusfomer) 5.Isthedeviceanewassemdly?� QYes c 2� Fire ❑ Type 7.Type 12. Initial��.,�e Date p,uNdahrl� L/s Time: _ PASS ❑ FAIL Final Da4e �mmidcyy): ,_. Time: _ []ppSS ❑ FA1L aIR GAp 15. Check Valve �F1 Held a�•� PSIP Closed Tight ❑ Leaked Held at _ PSID ❑ �Ctosed Tight ❑ Leaked and e-mail IniBal �g Telept Tester ,,,, .,.�? 22. Name Finat 24. Telepi Tesfer 26. Testin! address Check Valve #2 Held af _ PSID losed Tight ❑ Lealced Held at _ PSI� ❑ Closed Tight ❑ Leaked q oc p Pvg p sys ❑ AirGap ❑ ays nber of device�� X{.._ Pressure Differential Opened at � •�7 PSIp ❑ Did Not Open Air Iniet Opened at_ PSI� [J �id Not Open Check Valve Held _ PSID Opened at_ Opened at_ PSID Ps�p ❑ Pid Not Open ❑ Aid Not Open Checic Valve Hefd _ PSID AVB Onened fullu7 n Yes ❑ No Company name offester (if nenf cali6ration date 23. Gompany name i ❑ Bysigning ftvs Backflowtesirepo�f and checldng fhis box, I here6y ceriiiythat I am'Familiacv,�iffi fhe info�mation confiained in this form and fhaf to fhe Besf of my knowtedge and belief, such infotmafion is ftue, complete and accurafe af the fime ofihe test Page 2 of 2 , � (J i ,`,.ti, i a. � �.;i ,i `, ��a�r � ��' rt,� � i� �, :.�� FIRE ��ECIJRIiY �s i � �� , � �, i�� 7 F; L ��1i , ili' �J:i(;90�) i;vllc '1'Ei, , '.(�}', .- •., .. ;0 .�i`7,>,;:� '7 CE TO SERVICE LOCATION: � .�.';.��7O(ii i;i.l`(.) IA'".r y �l� /l`��C) .I�� ,!� � ( ril�. �,1 i . . �. ,.� i./l�i r�� ll�:r. i�l.��Sl4� 1(.�.1�.��+ ��Vi �� ._. A ti._. / I )��1 + t) � i � r��i lJ -i 1i�1)�C.�!,.,.Ji,LS� ll� ��s4G . ... . iillii�.1,`�Ui'"..,.�.G, 'o:S!O .... ..... :. � �i , .. r � i r n i i �l )�7 � � ,i � � i , i � � \�-� �L ��lil)ef �IL� �IU.�.�I��f�,%. t ( i ,. i - �� i t� � � �,i i� i � � ( 1.: � � � i i i . , . � 1 i � �_ I � � 3( i! � � I _. � � � I � 1 ,,. .� .. � J . ,_ . a . . � l) �,, .„S 1 �`l�l� �I ��, �,1�, , 1 ,, �� a � /. �, � U ] \ . .,. � .1 .4 � � ) � / J l 1 � a . 4f 7 � 1 L � / i ) � , t / l_ _ cl � � L1 � i�_ (..it LL`�,. . �, 'J� I'Cl , , �C7 , zi. Problems Pountl � �}'r l:. -, No.o( Podalto qrdvetl Oeparted p i /� / Technicians ServiceZone PodalTravelHre `C7t-- \� : V��'�' ��GS'4" �C��W`� _ .. �. n t'' � P� ,�[ `. ! s'P�;,., c� y�-� �l�o,t �1�..4 � � C. o c�.�„ o.� ,, TypeofSyslem Mawfaclurer �� ,,:. ��'(�,S � . .. , , ; � TroubleCaii � �Q�vv3 y .�_ '., �iau�ine Inspection � U—' Descripllon of Work Performed: : c �, � Jc Fla,,.� S� Company Name Last Service Date Material Used I�� 0("�� , . IEach .... IAmounl IDale (Technician � �- ::MaterialTotalForward .:� '- ` �� . The ahove inspection is made for the purpose of checking the machanical and/or electdcal operetion of lha equipment and nol lo delarmine or guarantee proper capacify, engineering or original ins�allation. �� 7otal �� Vendor shall not be responsible for the improper operetion of any inspected equipment thaf, aker serviceman has left premises, Labor Hrs has been discharged, vandalized, iampered wilh or damaged. Total �� The reverse of this agreement is inwrporated herein. Please read carefully. We are not an Insurer. Our maximum liability is Material._�, Ilmited to $250.00. User acknowledges receipt of copy and ihat he has read and understands �everse side of agreement � Sub-Total Xustom� nature, ��3� / � ITechnicia �Signature _ Date _ .. / L ^30...) �. salesTar . �� _.J —,___ .....: ry ll "' ._. . . - .. . . Print Customer Name 16mh4 i. � _ BACK�l.OW D�VIC� TEST . , Stata Form 957eR (2-1bJ �� . IN�IANAOEPARTMEN70FFNVIRONMENTALMANAOEMENT THIS FORMIS TO BE COMPLETED BYAN INP/AIVA CERTIF(�p BACXFLOIN iESTER. _��- o ^ ..n-� -. o , o.� . 1. Customer�ame � 2. Custamercompany � Pa rlu�.,o od � x� Pa r'1G�,,•no� 1( 3. Customeraddress(numberandsfrsef, e sfaie, andZlPcode � ROO �' �G'"^ �-� �... -�t;q....�t�o/� S =A1 yG2'�10 4. Location ofdev�ce (and addressif ddferenf from cusfomerJ 5. Is the device a new assambiv9 � 1-1 Yes I-�=1� 8. Type 13, z�1 f— l GCou� ;� mesflc ❑ Fire ❑ lrrigation ecti"on lation C7 Containment Check Valve #7 Initial �ate pNr✓aayy�: �M Held atg $ PSID Time: Closed Tight ASS � �eaked ❑ PAIL Final �ate �m�✓dryy�: � Held at_ PSID Time: ❑ �Cfosed Tigbt [] PASS ❑ Leaked ❑ FAIL AIR GAp Measured verticai i�ches above overFlow rim : 1Q Name and e-mail address f Inittal �g Telephonenumber 19. 7esfer __ _ r7� _ � IgRP p oc q pvs p sva ❑ nir �ap ❑ ava 9. Serlal num6er of device �%��0� � 12. Model number of device 0�9M� CheckValve#2 p�sureDifferenfial Airinlef � � R�lief Valve Held at PSID Opened at 2• 3 �Pened at_ PSI� PSID Did Not O en Closed Tight ❑ P ❑ Leaked ❑ Did Not Open Cfieck Valve Held _ PSID Neld at _ PSID Opened at_, Opened at_ PSID ps�p Did Nof O e ❑ Closed Tigh{ . ❑ p n ❑ LeaKed ❑ Did Not Open Checlt Valve Held _ P51� AVB diameter: �'G� Yes 1Z Company name of fester (if applicable) �� - — ' calibration date (mm/do ompanY name oftester Final 24. 7esfer 26. ❑ By sSgni��g fhis 6ackfiow fesfreport and ehecking fhis box, l here6y cerfify fhaf 1 am fiamitiarvaifh fhe infoima{jon contained in this form and thaE fo fhe besf of my knowledge and belief, such inforrttaf7on is irue, complete and accurafe a{{fi� time offihe fesi Page 2 of 2 , 6� <e E3AC4CF[.Olfl7 D�ViCF TEST i,� State Po1m S57ae (&ibJ +a ',� INo1ANADEpARTMEN70FENVlRONMENTA�MANAGEMEN7 7HIS FDRMIS TO B.E COMPI.ETED BYAN INII/AAIR CE'RT(FIED BAGKFLOINTESTER. e- , e.➢- ^ o , e. Pressure 1. Customer�ame 2. Custometcompany � �a�%waod T=X, �erandsfrsef, cify, state, andZlP � Q i r�.. f'+ —r 8. Type ofpro Ion solaiion ] Fire ❑ lrzigation [] Containment 13. Addifional information (optional) � CheckValve#1 Initial Data (mModryy)? 30 q Heid at �_Z PSIp Time: Closed Tight PASS ❑ Leaked [f pNL -- --- Final Date �rN,✓ucyyg u Held af ^ pSID Time: ❑ Ciosed Tight ❑ PASS ❑ Leaked ❑ FAIL AIR GAP M�asured vertical inches above overFlow rim : 16. Name and e-mail address 1 Initial 18. Telephone number 19. Tesfer r7� ' � 2D. Testing equipmenf serial 6 Z, �$O 22, Name and e-mail address of Finaf 24. Telephane number 25, Tesfer 26. Testing eqaipment serial nun a,-�w.odd �'�C e ;q.,..Pal:r, '�'nl ti6z5�o / 5. Is the device a new assemblv? � I—I Yes � �RP �] DC ❑ pVB ❑ SVB ❑ Air Gap ❑ AVB 9. Sedal number of device Z 73ZS7 Check Va(ve #2 Held at PSID Glosed Tight ❑ Leaked Held at _ PSID ❑ Cfosed Tight ❑ LeaKed size Opened at 3_g PSID ❑ b'td Nof Open a Air Iniet Opened at_ PSID [] Did Nof Open Check Valve Held _ PSID Opened at _ Opened at_ PSID PSIp ❑ Did Not Open [] Did Not Open Check Valve Hetd _ PSID AVF3 17. Company name r name n n�m6er of fesEer 27. Testing equlpment ❑ BysignSng fhis hackflowiesf report and checIang this box, l here6y certiiythat I am fiamiliarwifh fhe informafion contained in this form and fhaE to the 6est of my knowledge and be[ief, such informaf7on is �true, complete and accumfe atfhe fime of the fesfi. Page Z of2