2011_0119 (2)BACBFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PROPERTY: Wa I q i n S 4418
MATTING ADDRESS: 313 N Den o n Ta nn R d _
C1TY--CQ f1r]_Q H I STATE TX ZTP 7 9 0199
CONTACT PERSON:
LOCATION OF SERVICE:
• • • : • •
THE BACKFLOW PREVENTION ASSEMBLY DETAILED D BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED
BY CMM'ON REGULATIONS AND IS CERTIFMD TO BE OPERATING WITImN ACCEPTABLE pARAME tS.
TYPE OF ASSEMBLY:
O REDUCED PRESSURE PRINCIPLE 0 REDUCED PRESSURE PRINCIPLE- DETECTOR
DOUBLE CHECK VALVE O DOUBLE CHECK DETECTOR
PRESSURE VACUUM BREAKER ❑ SPILL RESISTANT PRESSURE VACUUM BREAKER
MANUFACTURER _ W I I k I n S SIZE 6'1
MODE. NUMBER Q SERIAL NUMBER -Dn % 9 % a
LOCATED AT LP.ft r ar of property
Is the assembly installed in accordance with manufachuer recommendations and / or local codes ?
TEST GAUGE USED:Make / Model SN: O Calibration Date: 7-0�
Remarks:
The above is certified to be true at the time of testing
Firm Name CHARIER FIRE PROIEC110MINC. Certified Tester
Firm AddmsrP.O. BOX 4578 Cert. Tester o.
* PASADENA TX_ 77502 /I/ ���/
Firm Phone # 713/472-0657 u
Th
TEST RECORDS MUST BE IEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURERS REPLACEMENT PARTS
8 ON)
6 t OS L X1119"(13
-pa del uoluaQ £ t £
""` Z" rxr''""u�, FRiNCIPLE AsSEI�i.Y
PRESSURE VACUUM BREAKER
DOUBLE CHECK VALVE
ASSEMBLY
T Check 2 Check �� V�-�
AIR INLET
CHECK VALVE
INITIAL
Held
at�id
Hel
Held at_psid
TEST
Closed tight
sid
Closed tight
ed
at_____psid
Opened
at_psid
Closed tight ❑
Leaked ❑
Leaked ❑
Leaked ❑
Did not open ❑
Did not open ❑
REPAIRS
AND
MATERIALS
USED
TEST
AFTER
Held
Held
Opened
Opened
Held at„_jsid
REPAIR
at
Closed tight ❑
at__psid
Closed tight ❑
at_psid
at__psid
TEST GAUGE USED:Make / Model SN: O Calibration Date: 7-0�
Remarks:
The above is certified to be true at the time of testing
Firm Name CHARIER FIRE PROIEC110MINC. Certified Tester
Firm AddmsrP.O. BOX 4578 Cert. Tester o.
* PASADENA TX_ 77502 /I/ ���/
Firm Phone # 713/472-0657 u
Th
TEST RECORDS MUST BE IEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURERS REPLACEMENT PARTS
8 ON)
6 t OS L X1119"(13
-pa del uoluaQ £ t £