2011_0119BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PROPERTY: 14418
MAILING ADDRESS: 313 N Denton Ta )12 Rd _
CITY--CQ 2h p l l STATE_ TX ZlP 7J 9
CONTACT PERSON: PHONE 979 469 R 9 6 5
LOCATION OF SERVICE:
THE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED
BY COMMISION REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARANWrERS.
TYPE OF ASSEMBLY:
❑ REDUCED PRESSURE PRINCIPLE
DOUBLE CHECK VALVE
PRESSURE VACUUM BREAKER
C] REDUCED PRESSURE PRINCIPLE- DETECTOR
❑ DOUBLE CHECK DETECTOR
❑ SPILL RESISTANT PRESSURE VACUUM BREAKER
MANUFACTURER Wilkins smE 3/4"
MODEL NUMBER — 9 5 n X SERIAL NUMBER Q i 4 2 7 a
LOCATEDAT deft rear of rl erty sprinkler pit
Is the assembly installed in accordance with nmufaceuer rmommendations and / or local coda? -
TEST GAUGE USED:Make / Model*C ��SN: alibtation Dec: 0-X
Remarks:
The above is certified to be true at the time of testing
Firm Name CHARTER FIRE PROTECTION INC Certified Tester
Firm Addm5rP.O. BOX 4578 Cert. Tester A.
PASADENA TX 77502
Firm Phone # 713/472-0657 Date
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURERS REPLACEMENT PARTS
313 Denton Tap Rd.
Coppeii, TX 75019
04418
xruut,r.� rRESSURE PRIIJCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CI�CK VALVE
ASSEMBLY
1 Check 2 Check RELIEF VALVE
AIR INLET
CHECK VALVE
INITIAL
Held
Held
6
Held at_.psid I
TEST
Closed tight
Clos� tight
at__psid
at Opened psid
Closed �
Leaked ❑
Leaked ❑
Leaked O
Did not open ❑
Did not open ❑
REPAIRS
AND
MATERIALS
USED
TEST
Held
Held
Opened
Opened
Held atpsid
AFTER
atypsid
at__psid
at__psid
at_psid
REPAIR
Closed tight ❑
Closed tight ❑
TEST GAUGE USED:Make / Model*C ��SN: alibtation Dec: 0-X
Remarks:
The above is certified to be true at the time of testing
Firm Name CHARTER FIRE PROTECTION INC Certified Tester
Firm Addm5rP.O. BOX 4578 Cert. Tester A.
PASADENA TX 77502
Firm Phone # 713/472-0657 Date
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURERS REPLACEMENT PARTS
313 Denton Tap Rd.
Coppeii, TX 75019
04418