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Home My WebLink AboutParkwood 7 (280 E. 96th)�ys��ms ��ernvice o '," " " � � _. ' _ _ _ , FO�IE � SEC��..OAA�'Y � � ;_. _� � INVOICE TO: - - ; I F; : I �, �� ;� �i '�: �l CUSTOMER AUTHOP.IZATION: X SERVICE LOCATION: _. : J _ _: � , � ': . _. DATE DUE: _ , . . , ,_ ._ _ . _ , . - - - - �_'„` �.'r'� I I l.� 1 -_i�J:�il�i ��,. i Uv�J I V v,=1��_ � ✓� i �.� .'� _..= 1... �� I �-.� i. � I:l1U � I! � w _.� 1:� ��J11"ial'i.i"C � I�.'"c.�.�. j i I.:.'"vlil ��;.i.� ... �.._. ,,��:�, �.':i,ylL r^ . � - - - - - � � 1 � �� i v -' I_.� �<.. i �. . i •.� .. � �� _ .� _ � .. , ' / `. _. � _ . � -.. � : �� 't ^� �� .^.1:,i GC'.;C��—�^.i:7 ' :Vl ti. ' - .�_�_.i -_,,".. _'_ , f ..c_ ..vi 'i� � ,. �_.ii'�I ...�i -,__i No. of Technicians Service Zone _ �Z �r Type of System �r�,-�Q-�2Fla�J ❑ Tr ble Call autine Inspection Description of Worl< Performed: (C F-d-S �-v� �� •' -- /4-n ti�► � �k �l-r.� e�' C�s� a��.. � si1 e �,q.cic�rp-ws , ,�-G( a�,r-v�•2cJ 7`r s�� `� �'i4-�� at /� C 7-��,..� 7v n��,�.,,4�f �;�.F't-,�- T� S hn'' Q -�-- - -__ _._ __ / Fire Alarm Coinpany Name Last Service Date �ty. 3 Il4aterial Used / r�-G` ` �� G�� Clean Agent CO2/FM200/lnergen Alarm I Each Amount Date �-� Aonitoring Access Control Secu Technician Hrs. Rate � �r s�. �i�� The above inspection is made for the purpose of checicing the mechanicai and/or electrical operation of the equipment and not to determine or guarantee proper capacity, engineering or original installation. Vendor shall not be responsible for the improper operation of any inspected equipment that, aHer serviceman has left premises, has been discharged, vandalized, tampered with or damaged. The reverse of this agreement is incorporated herein. Please read carefully. We are not an insurer. Our maximum liability is limited io $�0.00. User acknowledgesseceipt of copy and that he has read and understands reverse side of agreement. :\ Custo e�'s S�i� ature ;� �� DaYe Te ici s Signat� Date x � � �=�j �`-�--7s�-�� %' Z� �ZnL� i � Print Customer Name `�-�y�,��..�'"-""—"' "---� C �r-- Portal to Portal Travel Hrs. Arrived � z-� Manufacturer Problems Found: DepaAed � ... . _ . .. . . , . , . . -> -. . �� /!J .. ,�5iiiitt,, s�.d'�'iG61Ct4n� - -..�''.o:Y��:s:�dr":�. .16 .i�ts'P'"�`"�' . Total Labor Hrs. Total Material Sub-Total Sales Tax Total Due m Video Surveillance Labor Charge �� -� ��,� �. �.� -��- � �� 1 � Gl 7 ` � �� hH^. 4TC oj/�• .�i�-9� I�!� �'o�p�1�1 ypg �,p '5� 1C �57�I� �1^ ��`�� I�{-yu.al(\lllL�llil 1�1�}l��dL II IL:� Il ,��J> S{aie Form 55789 (2-1� +Y�jr INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT �nin 7'H�S F"ORlii/ IS TO $E COMPLETEI7 BYAN ItUD1ANA CERTJFI,Et] BACFtF�.O W T.EST.E'R : , . :� � __ ._. . ,. . : o ._..o1n___ "- p. ' o" ��: ._ _. _._�_:.._ . . . , , _�1- __ �__ _ _ -- __ - '(. Customer name 2. Cusfomer company � .-' %�i 'l- K i.ty C�O .Jj �� 1 3. Customer address (number and sfreet, ci�}; sfafe, and .ZIP code) � 2. �s'C� C: � � 1 Cs �l-ti 5/ =% -I-��. <-' -J=a n �( � S •�.v �� =/� z�i C� A. Location of device (and address ifdifferenf from cusfomer) 5. Is the device a new assembly7 ❑ Yes ❑ No Re laoin. serial number: 6.Type ofservice 7. Type of assem6ly omesfic ❑ Fire ❑ Irrigation ❑ RP ❑ DC ❑ pVB ❑ 5VB ❑ Air �ap ❑ AVB 8. Type of profection �� 9. 5erial number of device ❑ lsolation f�( Containment �7� G /� Z.. S/ '10. Size f d vice 19. Manu actur r of de ice 12. Model number of device �� J7(� �/l%i ! l�i S' i� a J n -�� ., . 13. Additional information (opfional) Check Valve #� Iniiial % � , Date �m,�d�yy�: J`'�' Held at �� s PSID Time: � losed Tight PASS ❑ Leaked ❑ FAIL Final Date �m,Nddyy�: Held at PSID Time: ❑ Closed Tight ❑ PA55 ❑ 1.eaked ❑ FAf�. AIR GAP Measured vertical inches above overflow rim : �5. Comments _'�lE�_ U'(�,+�I l'I [�b'3 r I K- RP DC Gheck Valve #2 Held at z•" PSID ❑ Clased Tight ❑ Leaked Held at PSfD ❑ Closed Tight ❑ Leaked Supplv size diameter: Pressure DifFerential Relief Valve Opened af P51f7 ❑ Did Not Open Opened af P51� ❑ Did Noi Open Alr Inlet Opened at PSID ❑ Did f�of Open Check Valve Held _ PSID Opened af PSID ❑ Did Not Open Check Valve Held PS1D r� ��-. Yes U No J �6.. Name,�nd e-maFi! address oftester 17. Company name of fester (j�fapplica6le)��•i �� y'� /�J-'1 L � �`�^�e`'L • t; / / � �V'C- �� C'� C° ��,S�:l ;: ./ ��% !L-� � J� Initial �g. Telephone numb�r 19.,,Sigrr�t�?��-ar��J re�fs ation numb�fesfer ' 4 �� G_�3 � Tesfer '��ia `��% � � C � `r'_.�` l O � 20. Tesfing equipment serial num6er �' 27. Tesfing equipment calibration date (mm/dd/yy) �-' �" � � �' �� ' 2� 22. Name and e-mail address of tester 3. Company name of fester (if applicable) Fina1 24. Telephone number 25. Signature and registration number of tester Tesfier 26. Testing equipment serial number 27. Tesfing equipment calibration dafe (mm�dd/vv) • Sy signing this bacIcflowtest reporiand cheaEcing fhis box,1 hereby certify fhai t am fatniliarwifh fhe informafion confained in fhis form and fhat fo fhe besfi of my knovvledge and belief, such information is frue, �omplefe and accurate a� the fime of the test. � Page 2 of 2 Citizens Utilities; Indianapolis Backflow Prevention Assembly Test and Maintenance Report citizens `��.,_.-<�' �.' � � �" � �/ � E�'� � � ,::�;., f� JGallagher@citizensenergygrou� Customer Information Name CITIZENS ENERGY GROUP WATER CUSTC Contact Address 280 E 96TH ST INDIANAPOLIS, IN 46240 Residential [ ] Non-Residential [ ] Assembly Test Report Initial Test Check Valve #1 2.5 [ ] Closed Tight [x] Leaked Assembly Information Type DC Size 0.75 Manufacturer Watts Location RISER RM Hazard ID 3771278 Check Valve #2 2.8 [ ] Closed Tight [x] Leaked Model 007M2QT Serial# 199251 Hazard FireProtection Final Test Repairs and Notes: Tester Information The backflow prevention assembly delailed on this form has been tested and mainlained as required by codes and regulations, is certified to be true & accurate, and is operating within acceptable paremeters at time oF testing. ' Only Manufacturers replacemenl parts have been used. "Tesl records must be kept for a minimum of three years Tester Name Tester License Expiration Certification # Test Kit Mfr & Mod # Serial # Company Address Phone Michael Price - Koorsen Fire & Security Indianapolis BF18-6101 Midwest 835 11132519 Koorsen Fire & Security Indianapolis 2719 N Arlington Ave Indianapolis, IN 46218- (317) 542-1800 PASS Test Date: 07/20/2020 Date Submitted: Awaiting Payment �'� 2 �� o �N� �,r� �,�, ..3�v� �� L�3I-�c�f�ilF�L�ihi C��i4Bu�L 1T��TI ��> Siaie Form 5578e (2-15� M1� INDIANA DEPARTMEN7 OF ENVIRONMENTAL MANAGEMENT 7"His F'ORtVI 15 70 BE COMPLETED ,�YAfV lIUDIANA CERTIFI.ED BACKFI.�W T,E57�'R. � :. : , ,_ _ � , ,�,,,�� _-,. � �'. � , ., �j-�y� �_ - __. �.:��,.. _ :_ _..�._. ' � `=�,^a="-a-4^h�au�1JIA°J��_ o.��T.• °.�r�.�:-:.:. _. .. . .... _ . _ - — . ' . ' ,: . _ . :,, _ , .,,. .. . _ _ . - -.. .: _. -........�. . . _. _ .. 1. Customer name 2�usfomer company i lJ <Z!L W �)�J'�' ( �� 3. Cusf�r a�l �ess (numberand sfreef, city, state, and ,ZIP code) SS C� L= • 7 `� `li �i �� /fl �"� / ��.')c.��,: JN,/1 �Ll (% � •�—�-��vr� `-1%G `z Ll a A�. Location of device (and address ifdifferent from cusfomerJ 5. Is the device a new assembly? ❑ Yes ❑ No Re laoin. serial number: 6.Type of s nrice 7. Type of assembly Domestic ❑ Fire ❑ Irrigation P ❑ DC ❑ PVB � ❑ 5VB ❑ Air Gap ❑ AVB 8. Type of profecfion 9. erial numberotdevice ❑ lsolation Containment �- �= j v� � 10. Size�f dey�ce 11. anuf�cfu� of d� ice 12. Mo�l number o d�ce i/ f � �3. ACidltlollal Inf�rmatinn /nntinnall Check Valve #1 Inifiial � Date mm/dd/ �� ( n9: � ' yHeld af � lPSID Time: / � Closed Tight PASS � Leaked ❑ FAIL Final Dafe �mmiddiyy�: Held at PSID Time; ❑ Closed Tight ❑ PA55 ❑ Leaked ❑ FAti. AIR GAP Measured vertical inches above overflow rim : 15. Comments RP RC Check Valve #2 Held at PSID ❑ Glosed Tight ❑ Leaked Held at PSID ❑ Closed Tight ❑ Leaked _ 5upplv size diameter: : r.: � t t yt. f j`�' q ------ _._ . . _ _ __ PVB15V� Air Inlet Opened af PSID ❑ Did Nof Open Check Valve Held PSID Opened af PSID ❑ Did Not Open Check Valve He1d P51D AVB Yes ❑ No � i6.. Name and e-majl address offesfer 17. Company name of fester (j�fapplica,b/e) �'�%,r ��--��• ,,`�-°¢ti. L r}� �� - � ��s�; ;:.. ,�; ,��, � �.� Inifial � g Telephone numb�r � 9.ySigrr�'tilrt-ar��J re is afion number of fesfer r�ter ��a `:�°? t 3 �= = � . � ,..�..-�----. �i � � �b — (03 � �` 2D. Tesfing equipment seria! number 21. Testing equipment calibration date (mm/dd/yy) �` a` �' � � � �� ' '2� 22. Name and e-mail address of fesfer 3. Company name of tester (if app/icable) Fina1 24. Telephone number 25. 5ignature and registration number offester TesEer 26, Testing equipment serial number 27. Testing equipment calibration dafe (mm�dd/vv) • �By signing fhis bachtlow�est reportand che�king �Ehis box, l hereby certify ihai I am iarr�iliarwifh the infotmafion confained in fhis form and thaf to the besf of my knowledge and belief, suci� informafion is frue, complefe and accul'afe aithe fime of fhe �esf. I Pressure Differential Relief Valve Opened af � �1� P51Q ❑ Did Not Open Opened af P51D ❑ Did Noi Open �, Page 2 of2 Citizens Utilities; Indianapolis Backflow Prevention Assembly Test and Maintenance Report c�tizens ��. � � s � �' � � � rK� � � JGallagher@citizensenergygrou� Customer Information Name CITIZENS ENERGY GROUP WATER CUSTC Contact Address 280 E 96TH ST INDIANAPOLIS, IN 46240 Residential [ ] Non-Residential [ ] Assembly Test Report Initial Test Check Valve #1 8.8 [ ] Closed Tight [x] Leaked Assembly Information Type RP Size 1.5 Manufacturer Wilkins Location PENTHOUSE Hazard ID 3771280 Check Valve #2 N/A [x] Closed Tight [ ] Leaked Model 975XL Serial# 980890 Hazard Domestic Relief Valve 2.4 [ ] Opened [ ] Did Not Open Final Test Repairs and Notes: Tester Information The backflow prevention assembly detailed on lhis form has been tested and mainlained as required by codes and regulalions, is certified to be frue & accurate, and is operating within acceplable parameters at time o( tesling. ' Only Manufacturer's replacement parts have been used. "'Test records must be kept for a minimum o( three years Tester Name Michael Price - Koorsen Fire & Security Indianapolis Tester License Expiration Certification # BF18-6101 Test Kit Mfr & Mod # Midwest 835 Serial # 11132519 Company Koorsen Fire & Security Indianapolis PAS S Address 2719 N Arlington Ave Phone Indianapolis, IN 46218- (317) 542-1800 Test Date: 07/20/2020 Date 5ubmitted: Awaiting Payment