Affiliate Partner: Marmic Fire & Safety
Instructions
1. Schedule visit with store manager. Identify yourself as an affiliate partner of
Commercial Fire. Record the name and title of the manager with whom you made the
appointment and the date and time of the appointment:
Name _______________ Title __________ Date __/__/__ Time __:__ am pm
2. Check in upon your arrival at the store. Call Commercial Fire IVR using the phone
and tracking number above. If there are any issues using IVR, call Commercial Fire at
800-241-1277.
The customer requires successful IVR call-in and call-out per the instructions
provided. is an essential part of this work order. IVR must be successfully completed
for this work order to be complete. Failure to successfully IVR will result in a 10%
penalty on the entire amount of the invoice for this work!
3. Scope Of Work:
Perform annual inspection of ALL BACKFLOW PREVENTION DEVICES LISTED ON
THE FOLLOWING SURVEY PAGE. IF THE PAGE IS BLANK, INSPECT ALL
DEVICES AT THE LOCATION.
If devices are listed on the survey page, ONLY those devices are to be inspected. Do
not inspect any devices not listed on the following page. If you believe that other
devices require inspection, you must receive authorization to complete an inspection.
A complete jurisdictionally approved inspection certification form must be completed
for each device inspected. One copy of each inspection report must be sent to
Commercial Fire with the signed/stamped work order, survey and deficiency form, and
invoice, and a second copy of the inspection report must be left on site with the store
manager.
4. Additional Work If you find additional work that can be repaired on site, call the
IVR phone number and hit option 2 to request authorization. If work is authorized,
record the work authorized and the authorization number in the adjacent space.
5. Complete survey forms in their entirety. You must complete the Technician
Statement and indicate whether any additional work remains. You must have
signature on the Work Order.
6. Check out before departing from the store. Call Commercial Fire IVR using the
phone and tracking number above. Enter the Closing Check Out number:
____________________.
Service Location:
Tractor Supply #1279
1650 Denmark Rd
Union, MO 63084
US
Phone: (636) 583-0615
Work Authorized:
Back Flow
Inspection
4552631
Additional Work Authorization Number
Store Stamp
_________________________________
Customer Signature
_________________________________
Print Name
___________________ ___ / ___ / ____
Title Date
(use separate sheet if necessary)
Start Date: 7/1/21
Deadline: 7/31/21
IVR Phone: 844-325-8006
Tracking No: 179984123
Customer PO: 700000126
Commercial Fire, LLC
2465 St. Johns Bluff Road S, Jacksonville, FL 32246
800-241-1277 Fax 800-956-9789
Important Reminder:
CommercialFire Mobile App
is the preferred and fastest
method for check in/out
compliance!
Visit CommercialFire.com/CFConnect for
more information
Wo002 06/23/2017
Job 21918176
If the answer above is yes, describe every deficiency, detailing with particulars how this system is deficient. Separately
inspecting affiliate will provide Commercial Fire Inc. with a quotation (see below) for the cost to repair these deficiencies.
All deficiencies REQUIRE Photos
Description of all deficiencies
Please provide a complete price quote for the repair of these deficiencies, detailing the scope of work, the parts and materials
required and their cost, the number of men required, the number of hours of labor and the cost per hour to perform the repair
and all other charges. Quote must be broken down by Scope of work, Materials required, Cost of materials, Number
of hours (1 or 2 men) and Cost of labor, otherwise Commercial Fire will be unable to process quote for approval. Please
use the accompanying form.
Indicate whether any deficiency has been found at this location during the course of performing this work order, #4552631, by
circling yes if deficiencies were found or no if deficiencies were not found. If deficiencies were found, describe them below,
detailing with particulars how the system is deficient.
System has deficiencies: YES NO (circle one)
Name: ______________________ Signature: ______________________________ Date: ________, __ 20___
4552631
Technician
Statement
Service Location:
Tractor Supply #1279
1650 Denmark Rd
Union, MO 63084
US
Inspecting Affiliate:
Marmic Fire & Safety
3107 E Chestnut Expy Ste L
Springfield, MO 65802
Wo002 06/23/2017
1. AHJ Name: _____________________________________________ AHJ Phone: ________________________________
Inspecting Affiliate:
Marmic Fire & Safety
3107 E Chestnut Expy Ste L
Springfield, MO 65802
Service Location:
Tractor Supply #1279
1650 Denmark Rd
Union, MO 63084
US
Back Flow Inspection - Additional Information
2. Does the AHJ provide Inspection Documents that must be completed and returned to AHJ? Yes No
Asset Data
4552631
3. If not, does the AHJ require copies of company Inspection forms be submitted to AHJ? Yes No
1. Fire Main
Make: Ames Model #: Colt 200 Size: 4" Serial #: IE-0240 Type: DCA
Location: Specify Location Confined Space: No
2. Domestic Main
Make: Wilkins Model #: 975XL Size: 1.5" Serial #: 2969403 Type: RPZA
Location: Next to Sprinkler Riser Confined Space: No
Wo6005 3/23/2017
Notes:
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Special Instructions