The URL can be used to link to this page

Home My WebLink AboutMJ Wilkow 10333 - Backflow 1-31-20�ystems Service j.i �;.., ,.�.. 0 i �,i;(1 Gl-j0 , � . , i � ' � !I�� ; ... . . .' , . ,_ „ .,_. ..... i acr� ,� ... 1. ��,. i)r.Ci�1�1��e 0 � � -w �,, GiiiC ,... uvvv4�t !, �, SERVIGF� LOCATION; af � I I_ i�l .i;, 1, __ �'F�,r � ii)i' .� I', i,.. , rl i 1: i( L;Aid �ii I,.. .'�I i�id . �>;ll i:r�iv� P� � �. . I �� iv ; � �, I Y C( i7ii i� C V'I �IT I ., i'VG ., , iJi);. A d . 'Ji_J ,�, I.IJ ,�,.�, CUSTOMERAUTHORIZATION: � DATE DUE: / ' � 1 , `.' "�' , i iJ; I� . i � i �t �,t��: , 1.�, � �.'i , , _, �,1 �� i�� ,i�' i.,.. ';[� ,. � , �� , , , ,�i, .�,� .,, ._. . � ,,. ,� I I:i.i i ,�N i .i , �I - , � � , � �. , ��•1 i 'r; � _ � i ��I i ,�'�(�,��"> . � � � ��/,71� ^ � � � ' �'� � )I. ,:;�' < < No o( Pohal �o Technlclans ServiceZone portalTravelHw. Arrivetl Typ f Syst M f 1 � �;,��1�� ❑ T bleCall t ��.� Roulinelnspea�Ion Descrip�lon of Work Pertormed: Probiems Fountl: � �` �v6� %�ST,�C�-- 3 ,. ��.' L°; �Y � 4�d . . RI' ; c�, _ �,� �'� � , ... , .�. ..._ . ,_ .. ,. . . . , _ t �i CompanyNa Last Service . . _ _'—_�__..._._.;:.� The above fnspection is made for ihe purpose of checking the mechanical andlor electricai operafion of the equipment and not to �� determine or guarantea pmper capacily, engineering or original Instaliation. Vendor shall not be responsible for ihe improper operation of any inspected equipment ihat, aRer serviceman has left premises, �� Total � has been discharged, vandalized, tampered wilh or damaged. Labor Hrs. The reverse of this agreement is incorporated herein. Please read carefully. We are not an insurer. Our maximum liability is '7otal ""�� limited to $250.00. User acknowledges receipt o� copy and thal he has read and underslands reverse side of agreement Material ,. Customer's Signature � ,", ". Print Customer Name Sub-Total KF-018CRev.1/13 �� BILLINGDEPARTMENT IalUsed \j KA�`�� __ _..IEach_. . IAmount 'Date ITechniciary� IHrs. IRate �LaborCharge �9:� r . a; i � . :`;ts� ��;> e• s: �i-• �: •a i: e.. ��""��"�'� �"ustomeixa`nddDeuice$lnfBs`,maf:ion — �� - - S - � � S2f' f"�l.vv\ ofservice• []Aornestic tre ❑Itrigaflon ... p.�..i Cj f2P ❑ PVB ❑�VB Cf Air Gap ❑ AVt3 :vice �„ „ , v;:`,,, ; , CheckVa'Ive#'I CheckVaive#2 Pressur6Dil€elzn5al ' pjrTniet Reliefllalae Itti#fal ' r� - Dafa t�amyyy. - Held at �l � lA Held af �SID Opened at,_ �Petied at_ PSt� Tmte: ,_, PS1D ,_.,� osedTight osedT�ght , �DidNo�Open Lt�YASs j) Leaked Q Leaked ❑ Did Nof Qpen II�� Check Valva Held u PSIA Final ' Dafe f miae�yy�:,� Held af,_ PS1D Held ai_ PSiD Opehed af_ Opened a{^ pSID Time:,_, PsiA ❑ Ctosed Tlght C( Closed Tighf ❑ Pid Kof Open [] FASS [] Leaked ❑ Leaked ❑ Aid Nof Open II �� GheckValve He1d._ PSI➢ •AIR �P.P " ttva � Ini&at ys.T resfer 3' zo. r, 22 N� FInaI 24. Te Tesfer serial nUm6er [j Bysigning z6is Bac7cHowiesirepopEand shec7ring i'his hn fhis {orm and #hatfo fhe hesf af my lmov✓ledge and be�ief, Company name of tesfer /l�r�o�r-s � �t_22.i ��; - < ,. ,�,�. za, cnmpany name of fester {'r�appliea6le) 1�. lesting eqvipmehtcalihrafion daie (mm/ddlyy) X, I herehy catiiE�r¢hatlam fantiliarv�i'fh thainfoYmafion cnnfained in such infoz�nation isirue, complefe and aecwafeaEiheiime of'ths �esi; Pege 2 of2 . from: Sent: To: Subject: Carmel Backflow <Backflow@carmel.in.gov> Friday, January 31, 2020 3:11 PM Ali Polston We have received your response for City of Carmel Backflow Test Form Testers Email Select Tester From List Gauge Information ali.polston@koorsen.com MYERS, BRANDON_BF18-6100 11161044 Phone Number (317) 456-0301 Calibration Date 10-03-2019 Select Company Company or Self Coinpany Name KOORSEN FIRE & SECURITY Testing For Phone Number (317) 456-0301 Address Street Address: 2719 N ARLINGTON AVE City: INDIANAPOLIS State / Province: IN Postal / Zip Code: 46218 i Select Seivice Commercial Use MANAGER NAME or COMMERCIAL BC FORWARD CUSTOMER NAME Type a question N/A D�VICE Street name: North Meridian Street LOCATION House number: 10333 ADDRESS City:Indianapolis State: IN Postal code: 46290 Countiy: United States Existing, New or Replacing Existing Device Device Serial QA1796 Number Manufacturer of Ames device Device Size 4" Model Number COLT 200 Of Device Type of Containment protection Type Of Seivice Fire Type a question RIS�R RM Hazard Code DC Passed or Failed PASS __ __ _ DC � D� _ . , Check Vnlve #1 Iicid At W hat PISD I i Closed Tigh[ .... ..... � .... .__ I,ealeed � . Check Vnlve #2lleld At �Vhat PISD I ... .. ICloscd Tight ..... �.. � .... . . .... : Leal�ed I ....... .... � ...... ....... ...._.......... Date Time DC � °C _� �, cn�i� vAi�� ui a�ia ac w��ac risn � a2 � Closed Tigh[ ...... .. I .... �ITS . ...I � Leaked I ..... �`� ... .. �..... ...... .._.. .._.... 2 Date Time Device Pass or Fail CheckValveN2IIo1dAtWhatPISDI 4b I � Closed Tigh[ � � � � � � I YES . .I Lcaked � . .... � .. . N� I Ol/31/2020 9:30 AM PASS Device Tagged Yes Rp ! iir ChecleVnlveNlHel�AtWha[PISD �� ; Cbsed TigLt . ... .... . ... .... ........... .. .I . ...._. ......... ........ . ...... .. ......i . . I LexlreU Cheel< Valve #2 Held At What PISD � ...... ........ ........ ........ .._i. .. �I Closed Tight ...... ......... ....... ........ ......: . '�� Lcal<ed . �. . ....... . .... ... .. .. . . ... ... ........... � ��; Pressnre Differential RelieS Valve Openad A[ WhatPISD I . I Did NOT Opeu... .. . .. ..... ........ �. .. .. . ... . .. ... . .. .. . . �I... Date Time 0 Date Checl<Valve iSl Held At What PSID � ; . ... . ..... ... ......... ........ ._i.... CloscQ'ISgLt � Lealsd ....... .. . .. . ... . . . ... .. . .. ....... ........ ....... ..... . .....lil. Cheel<Va1veN2HeldAtWLntPSID � ClosedTigh[ ........ ...... ......... ..._' .. Lealced ... _.. ........ ..... . . . ..I ... Pressure Difrerendnl Relief Valve Opened At What PSID I ..._ ....... ........ .__ ....... Did NOT Open Time , PVB P� IiOpenedAtWhatPSID � . . , llid NOT Open.. .. .. . I... . .... . ..... _...._..._... . .... j Did OPF,N � � I . ...__...__........ , . . ._... ....... ..:.. ..... . .. jChecicValveHeldAtWhntPSID� . Date Time � � Opeued A[ WhatPSID ... .......... ; .... ..... ...... i Did NOT Opeu . I Did OPEN � � jCheck Vnlve Held At Wha[ PSD i..... ... ..... ... ..... . .. rvn _ _ Date 7 Tiine AIR GAP ONLY Final Test Results Date Time Testers Full Name: Date Time Measured ve hcal inches j aboveoverflo�vrim � AirGapl . � ..�I. ali.polston@koorsen.com O1/31/2020 3:10 PM Supplysizediame[er � ( .. .... .. ......I : �'s� a � ?��d4,�4��,t�°dUSfT9�f11�� OE�'6 ^ � S�te�BmiSE18P(2-i'�] � . . IN�IANRA�PARiMENr�FIIdvIRoNMENTAL f�qNACEMENI' Tf316P01216+lIS 7'O BECdMP.4�iF.fa BYAhA7h'A#ANA C.�k47F1E'p /3ACKF.tOTN'7�57'�R. 3. �] Donles�ic [j Fire �f profecfilon Cllsoiafion �Cnr GhechVa'We�E1 � �m9�uon ❑ tzp p nc 1� pva Ll suB ❑ Air Gap C] Ava S.SeriaCnumberoPdevJce : . , _, _ . F .... � „�' " '�� `»'.� .�� - f ;�. 5laviae 12.Madelnumbero4dev3ce`� ; , � �� r'��'�'-' `� 4 ' < r r � Ini�iat b� i�/�/�; ' Hetd at � '^�-fi51C rro,e: � �%Closed'IIghf � p�s [] Leaked _ Q PAiI. �inal Date � a✓a�yy�:,_, Heid af,� PS117 fine:,_ ' � ClosedTighf p pASS [] Leaked L7 FAI� tIR GAP CheckVat¢s�2 Presstuspii3erentia! ' pry�Tntet Relief Va[ve Held at _, ASID Opened a{ �.<f Operied at�, PSIn �ClosedT�qhi � PSIA , []QidNatflpen [ j Leaked �J Did Nofi open CheckUalve Held u PSID Held at� pSi➢ Opened at_ Opened at� PSID PSIp [7 Closed Tighf Q Pid l�of Open J� lea[ced Q Did PIoi Open Checkl/alve Held,_, PSID .....� � CJ�,_}� ��-i ' �t,��- �✓ �t�iux i.. � :f�at �� ,�_ �, , n {�`_t I�� 16. Telephone num6e Tesfer 3�� ` ''�� 2D, T ct e Gipmeni �'��r� 22. 7�tame aitr%mail � fiIn3I 24 Tefephone t3nmhei T�sfer 25 7es6na eqiripment lY, �1� �enE ca' �._ L3. li9IT Q Bys�qning fhisBackHourtesir�pot�and ehesking i'his T�aX,[ fietei�y cettiijtthatlatnianuliarwifih ttteinfomtaiioR cotttained "m t6is form and'thatin fEte Besf oi'my Imo�rIedge and heTief, sucH zofaltna#ion is hue, cnmplefe and a¢emxfeaiihefime of'the 4esL Page 2 nf2 . From: Sent: To: Subject: Carmel Backflow <Backflow@carmel.in.gov> Friday, January 31, 2020 3:14 PM Ali Polston We have received your response for City of Carmel Backflow Test Form Testers Email Select Tester From List Gauge Information ali.polston@koorsen.com MYERS, BRANDON_BF18-6100 1 ll 61044 Phone Number (317) 456-0301 Calibration Date 10-03-2019 Select Company Company or Self Company Name Testing Tor Phone Number ICOORSEN FIRE & SECURITY (317) 456-0301 Address Street Address: 2719 N ARLINGTON �VE City: INDIANAPOLIS State 1 Province: IN Postal / Zip Code: 46218 i Select Seivice Commercial Use MANAGER NAME or COMMERCIAL M&J WILKOW CUSTOMER NAME Type a question 60498767 DEVICE Sh•eet name: North Mexidian Sheet LOCATION House nwnber: 10333 ADDRESS City:Indianapolis State: IN Postal code: 46290 Counh�y: United States Existing, New ar Replacing Existing Device Device Serial 186332 Number Manufacturer of Watts device Device Size Model Number Of Device Type of protection Type Of Seivice Type a queshon Hazard Code Passed or Failed 2�� N/A COULD NOT READ Contaimnent Irrigation JANITORSCLOSET RP PASS _ .. DC nc � Chccle Vaive tll Heltl At What PISD I �ClosedTight � �� .. .. ILenked ... ..�. I ... ... � Checic Valve #2 Aeld At Whn[ PI9D I IClosed Tight . .. ... �� I .... .. ... ILeakcd �.. ... I ._... _.... �� Time DC . I nC I I Chccle Valve #1 Reld At W��a[ PISD )( ClosedTight I � . ...� _ IiLcalred ..... ..... � _- __...� , ..._........ _._... ._... 2 Check Valve k2 He1�3 At �Vhat PISD ; � Closed Tight ...... ..�� . . . .. .. ... . ...... . Lealced.. .... _'. . . . .. .. .. .... Date Time RP ' � Clieck Valve #1 Aeld At What PISD li I'�...... ... .... . . . . ................... �'�. Closcd 1'ight �I Leaked. ..... .. .. . ....... ........ .I.. .... Checl< Vnive NZ Ileld At NLat PISD �I , ......... ......... ..._ ............... '�:. Closed TigL[ j Leake� . ......... ... ... .. _... i .... Pressure Differential Relief Valve Opened At WhatPISD II . Did NOT Open . .. . . .. . . I . .. . Date Time Rp li Rr ci�e�kv��nix��antwn�crs�v I zs Closed Tight ....... ........ . ....... I YES ,�,, Lcal<ed . . . ... ... . . . .. ... ... ...... . . . i NO Checi< Vnive N2IIeld At Whaf PS1D �� .. . . .. ........... .. . . .. ..... ..�..... '��. Closcd Tight i YES Lealced . . . ... . ..... . . .. .. . ... ... . � NO Pressure D�fferential RelioP Valvc Opened A[ WhatPSID I 62 ...... �.. ..... .. . ........ ......... ......... ! Did NOT Opeu � Passed or Failed PASS Tagged YES Date 01/31/2020 10:00 AM Time PVB Date Opeued At Whnt PSID ; Did N01' Opcn � � � _.... ...... ..... ;Did OP�N Checic Valve Hel� At What PS[D .rvs Time PVB _ � rvs� � � � �O�enedAt�VhntPSID . . i . ............ . I ....... ._... . ...�....._... . . DidN01'Open ....._ ....._�. ...... ....... IDidOPF,N '. � . Checic Valve Held At Wha[ PSID I� � ..� .....I Date K Time AIR GAP I N[easm ed vcrtica� incncs ( _ � nbove overpow rim S"PP�Y size diameter ONLY Final � � I Test Results �^�r ��P � � � Date Time Testers Full Name: ali.polston@koorsen.com DaCe Ol/31/2020 3:10 PM Time �'��r�' ,t�:�l� �)i � i' i �� i��F i• � r: i-r• .��: �s • • I I s •. ��-��" ��: Custome^n�r» dio�uice�ln4ogma[iar�' j] Fre [] ]rrigafion � �. �, , � _�_�___:_,,..�.��_�.�? , �. � � � � � i' ■ - �. ■ ! �� ■ ■ � 1 IniHaI Tesfer FinaI � 2? TesfeY 25 $. � []AG []pVB ❑S.V6 []A'vGap []AVB �P 4 d�� 7�C� � ' Checl<Vatva�2 PressnrepiffereMia! ' pj�inlet ReliefUalve �r Held af ____, PS1D Opened aE � r�% Operied at^ PSID PS1A '��lased Ttqhi � ' , �1 p�d No� Open Leaked IIDidNofiopen CheckUalveHe]duPSID Held ai� pSi� Opened af� Opened a#,_, p5ip PSIp [7 Ciosed Tight [j Pid Nof Qpen Q Lea[ced ❑ J7id Nof Open Gheck Vaive Heid _ PS1D 'S'�@Y IIii0Yf312@IGEI � ' � � �— ( L ' � �€ �'� `-� � z�. �nmpanynameofiesfer [] $ysiynit�q ihis HaekflowiesEreporEand ehe�Iang fiIvs haX 1 here�y cetfiljr�Fha#Iamiap�ilial�wifiit fha5nformafian contaSned in t6is �'nrm and #hatfa �e hesfvfmy Cmocvledge and keTiaf, such znfoYmation is�rue, cumplefe and accwxieafPFzefmm oftfie tesi Page 2 of2 . � •� � From: Sent: To: Subject: Carmel Backflow <Backflow@carmel.in.gov> Friday,lanuary 31, 2020 3:18 PM Ali Polston We have received your response for City of Carmel Backflow Test Form Testers Email Select Tester From List Gauge Infortnation ali.polston@koorsen.com PARKER, RUSSELL_BF18-6336 11161044 Phone Number (31'� 456-0301 Calibration Date 10-03-2019 Select Company Company or Self Company Name Testing For Phone Number KOORSEN FIRE & SECURITY (317)456-0301 Address Street Address: 2719 N ARLINGTON AVE City: INDIANAPOLIS . State / Province: IN Postal / Zip Code: 46218 i Select Service Commercial Use MANAGER NAME or COMMERCIAL M&J WILKOW CUSTOMER NAME Type a question 38356831 DEVICE St�eet name: North Meridian Sh•eet LOCATION House number: 10333 ADDRESS City:Indianapolis State: IN Postal code: 46290 Country: United States Existing, New or Replacing Existing Device Device Serial 3916445 Number Manufacturer of Wilkins device Device Size 1" Model Number 975x12 Of Device Type of Containment protection Type Of Service Domestic Type a question PENTHOUSE Hazard Code RP Passed or Failed PASS _ _ _ DC i nc _ cno��v��ai aeia ar wbar ris� ( cros�a rsi�c I _ � Lenked .... _, � .. . . ... Chcck Vnh�e #2 Hcld At WhatPISD.� .. , Closed Tiglit ....... . ....I ...... . . .. .. iLealced .... ..-.I .... .._. Date Time DC � D� I Icn<d<v�me ui a�ia nt wnat rrsn I � closea Tighr � � � Lcnlce� .. ... I . .... 2 CliecicValve#2He1dAtWhatPISDI . . . J I Closod Tight . � � Leaked ... ... ��. ..... ...I Date Time Device Pass or FAIL Fail RP j � �� Checic Valve Nl Hcld At What PISD �� ....... ........ ...... ; '�. Closcd Tigh[ . .. ...... . . . .. � Lcalced .. . .. . ... ..... ...... .. . � . . Check Valve p2 Aeld A[ R'hat PISll.. I �, Closed TigLt . .... ... � .. ... ....... ....... ........... .. I �� Lealced .. ..... .... ... ..I . . Preasure DifferenHal Relief Valve Opened At What P7SD I I .... ...... .... ........... �, '�,. Did NOT Opcn I " Date Time � ............... 'iRP �... . . . . ... ........ ..... .... ....... ! Checic Vaive #1 Held At Nhat PSID i 146 Clased Tight .. ... .. .... ... .. .. .. . .. . I YES ........ ...... . ...... ....... I I Lealeed . . .. � NO C4eci<ValvefKlHeldAt�VhntPSID � � � ...... . .... .. ......... ... ...... �, ..._. � Closed Tigh[ ; YES ...... ....... ....... � Lcake�._.. ._..... ...... ......_ I NO PressureDiffereotialReliefValveOpencAAt�Vha[PSID� 1.6 .., Did NOT Opeu .. .... ... ..... ...... .... . ... ......... ...... ... I... Passed or Failed FAIL Tagged YES Date Ol/31/2020 11:30 AM Time Notes : RELI�F WOULD NOT OPEN ABOVE 2.0 PVB � p�B _ � o��a�n nc w�at rsm I � Did NO'P Open I . _ . ..I I Did OPCN .. . I .... . .I j Checl<Valve Held At What PS1D I Date Time PVB I _ p� I Opene� At WL�t PSID .. I. . ..... .... . .. ...I 3 Di� NOT Opm� .... I .. . . . . . . . � i Did OP�N . .. I.. .. ..... � Check Valve Held At What PSID I. �. � I Date Time �11R CTE� �� Measured vert al �ches '�,. Snppiy size dixmeter �' �NI.y FIri21 I abovo overFl ry im y I i TestResults ^'rcaPj � I Date Time Testers Full Name: ali.polston@koorsen.com Date Ol/31/2020 3:10 PM Time n