HomeMy WebLinkAboutJ332 Backflow testBackflow Prevention Assembly Test and Maintenance Report
Customer Information Assembly Information
Name
Ar chon - Citizens Utilities; Indianapolis
Kroger #332
Contact
Type RP
Address
Size 1.5
10679 N Michigan Manufacturer Wilkins
Location Zionsville, IN 46077-Dock area by fire protection riser
Model 975XL2
Serial# 1606984
Hazard Domestic
Assembly Test Report
Initial Test
Final Test
Tester Information
Tester Name
Repairs and Notes:
Hazard ID 3876348
Test Date:
BF18-6087
3241 N. Shadeland Ave
11/20/2018
Donald Cooper - Kroger Facility Engineering
Tester License Expiration
Certification #
Test Kit Mfr & Mod #
Company
Serial #
Midwest 845-50029
01181525
Kroger Facility Engineering
Phone
Indianapolis, IN 46250-
317-543-3588
Address
Check Valve #1 Check Valve #2 Relief Valve
8.2
[x]
[ ]
Closed Tight
Leaked
N/A
[x]
[ ]
Closed Tight
Leaked
2.8
[x]Opened
Did Not Open[ ]
PASS
The backflow prevention assembly detailed on this form has been tested and maintained as required by codes and regulations, is certified to be true & accurate, and is operating within
acceptable parameters at time of testing. * Only Manufacturer's replacement parts have been used. **Test records must be kept for a minimum of three years
Date Submitted:
Residential Non-Residential[ ][x]
01/28/2019