HomeMy WebLinkAboutBackflow 3-9-2020SERVICE WORK ORD�R
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MER BILLT JOB NAME & LOCATION�
COLLIERS TNTERNATIONAL COLLIERS IN7ERNAiIONAL
241 N PENNSYLVANIA ST 12955 OLD MERIDIAN
SUITE 300
INDIANAPOLIS, iN 46204 CARMEL, ZN 46032
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REQUESTED FINISH DATE CUSTOMER PHONE JOB PHONE
317/713-2100 317/713�2130
SPfCIAL INSiflUCTI�NS
PATT] 317-713-2130
CONTRACT HOTES
(11DO�IE511C #300329(1"MECH RId� +IdUST SCHEDULEg
COHTACT; PATTI 713-2130 PWNIPPLE�SUMMITREAIiYGAOUP.COM tSPK
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The above inspection is made for the purpose of checking the mechanical and/or electrical operetion of ihe equipmenl and not to
determine or guarantee proper capacity, engineering or original installation.
Vendor aheil not be responeible for the improper operatlon ot any inapecfed equipment thet, after serviceman hea lefl premlaes,
has been discharged, vandelized, tempered with or demaged,
The reverae of this egreement Is Incorporated hereln. Pleaee read cerefully. We are not en insurer. Our maxlmum liebility la
Ilmited ta $250.00. Uaer acknowletlges receipt of copy and thet he has reed entl understenda reversa side oi agreement.
Cuatomer's Signetu� Date Techniclen'e I ture Deta
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20.
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Check Valve �2
Held at_____ PSID
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number
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PSID
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PSIp
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❑ Bysigning this bacicf/ox iesireporiand checking ti�is 6oX, f here6y ceriiiytbatl am familParLvifh }beinfot7nafion confained in
fhis fptm and thatfo fhe besf of my knowtedge and 6ellef, snch in%rma8bn is five, complefe and accumfe at�fhe fima ofi�he test
� � Page2of2 .
From:
Sent:
To:
Subject:
Carmel Backflow <Backflow@carmel.in.gov>
Monday, March 9, 2020 3:53 PM
Morgan Pickett
We have received your response for City of Carmel Backflow Test Form
Testeis Email
Select Tester From List
Gauge Information
Phone Number
MORGAN.PICKETT@KOORSEN.COM
ROACH, DAVID BF15-5322
06150748
(317) 542-1800
Calibration Date 07-31-2019
Select Company or Self Company
Company Name Testing
For
Phone Ntunber
KOORSEN FIRE & SECURITY
(317) 542-1800
Address Sh•eet Address: 2719 N ARLINGTON AVE
City: INDIANAPOLIS
State / Province: IN
Postal / Zip Code: 46218
Select Service Use Commercial
7
MANAGER NAME or
COMMERCIAL
CUSTOMER NAME
Type a question
DEVICE LOCATION
ADDRESS
E�cisting, New or
Replacing Device
Device Serial Number
Manufacturer of device
Device Size
Model Number Of
Device
Type ofprotection
Type Of Seivice
Type a question
Hazard Code
Passed or Pailed
DC
Date
Time
DC
Date
colliers inteinational
53477767
Street name: Old Meridian Street
House number: 12955
City: Carmel
State: IN
Postal code: 46032
Country: United States
fixisring
300329
Watts
1
009m2t
Containment
Domestic
riser rm
RP
PASS
�!Checl<VniveHlIleldAtWhatPISD�� �
: Clased Tigh� . . . . ..... . . .. .. .. ... . . . .
� Lcalmd . �� . . .... ..
i, .__._...
; Checic Vake p2 Held At What PISD f �
, Closed Tight ..... . . . . . . . . . ... ... . . . . . . ..
L�a�z�a
nc
nc
_ _ _
Chectc Valve #1 Hcfd At WLat PISD I .
ClosedTig4[ . . . . .. . . . . I. . . .
... . .... .... ...... ........... ..
LCAI<Cd � . .. . . .. ..........
Checle Vnlve #2 Hel� At W hat PTSD � . . .
Closed Tight �
Lealced....... .... . . .. � ....... . .............
z
Time
RP
Date
Time
RP
Passed or Failed
Tagged
Date
Time
PVB
Date
Time
�UB
Date
Time
' xe
CLeck Valve #1 Held At WLat PISD !
.... ... ...... ... ....... .. .. . ... . i....... ........
Closed 1'ight �
.. . . .. ..... .... . .. . ... ...... _..... _...
Leaked
ChcctcValvett2lleldAtWha[PISD �'
CloscdTigh[ . . .. ...... . . . .....i. .. .. ......
Lealced �
i
i
Prccsure Differerttinl Relief Valve Opened At What PISD `
Did NOT Open �
���, Checic Vnlve Hl Held A[ What PSID I
�'I Closcd Tight �
I
; Lea�cea.. . . . .. . .. . ... . . . . . i
'�, Checic Vnive #2 Hel� At WhatPS1D �
� Closcd Tight . . . . .. . .. .. . .... .. .. �i
' Lcalccd . .. . . . . . . ..... . ��'
� Pressm�e Differential Raliof Valve Opened A[ Wha[ P6ID �
�I Did NOT Open .. .. . . . . .. i
PASS
YES
03/09/2020 11:30 AM
i
Opened A[ What PSID !
i Did NOT Open j�
ii� Did OPLN . .. . . . . . I..
".,. ...............i.
I Checl< Valve Held At WhatPSID I
Rr
9.0
Y
n
. ... Y.... .
22
. ... Y . .....
.. . PV13... . ..... ..
. . . PVB.. . .
Opene�AtR'hatPSID .......... '�I . . . .. . . .. ... ...
Did NOT Open ....... . .... I .. .. . .. . . .... _ _.. ...
Did OPPSN � .. .. .. . . .
. .. ... . . . . ;... ......... . _.. ......
Checic Valve Held At �Vhat PSID �
7
AIR GAP ONLY Final
Test Results
Date
Time
Testers Full Name:
Date
Time
; Measured verlical inches ����. Sup�ly size diameter
'�. above ovcrtlow rim
� Air Gap I . . .. . ... . . . . . . ... .. . . . . .. . . . .
MORGAN.PICKETT@KOORSEN.COM
03/09/2020 8:30 AM
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