2011_0119 (3)BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF • I , • - -n ; II
MAILING ADDRESS: 313 N Denton TapD Rd
CITY — fD-P Ej I STATE T)C zw 7 5n i q
CONTACT PERSON:
LOCATION OF SERVICE:
• • I• :••
T'HE BACKFLOW PREVENTION ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED
BY COMMISION REGULATIONS AND IS CERTIFIED TO BE OPERATING WITHIN ACCEPTABLE PARAMETERS.
TYPE OF ASSEMBLY:
1A REDUCED PRESSURE PRINCIPLE ❑ REDUCED PRESSURE PRINCIPLE- DETECTOR
D DOUBLE CHECK VALVE ❑ DOUBLE CHECK DETECTOR
❑ PRESSURE VACUUM BREAKER ❑ SPILL RESISTANT PRESSURE VACUUM BREAKER
MANUFACTURER watts SIZE 1 /2
MODEL NUMBER so SERIAL NUMBER 7 2 A 13
LOCATED AT Photo a b
Is the assembly installed in accordance with manufacturer recommendations and / or local codes ? ye _
TEST GAUGE USED:Make / Model �1 �1�$f ;j � SN: AQ�alibration Date:-,0?,
Remarks:
The above is certified to be true at the time of testing j
Firm Name CHARTER FIRE PROTECTION.INC, Certified Tester Gad /iV
Firm AddregS-P.O. BOX 4578 Cert. Tester No. 11z z
PASADENA TX. 77502
Firm Phone # 713/472-0657 Date / --
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURERS REPLACEMENT PARTS
313 Denton Tap Rd.
Coppeli, TX 75019
04418
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
DOUBLE CHECK VALVE
ASSEMBLY
I"Check 2 Check RELIEF VALVE
AIR IN
CHECK VALVE
INITIAL
Hel
at �sid
Held
ed
Opened
Held at_�sid i
Closed tight ❑
TEST
Closed tight
_�sid
I Closed tight
at -, sid
at_psid
Leaked ❑
Leaked ❑
I Leaked ❑
, Did not open ❑
Did not open ❑
REPAIRS
AND
MATERIALS
USED
TEST
I Held
Held
Opened
Opened
Held at_psid
AFTER
at_psid
at____psid
atpsid
at�psid
REPAIR
Closed tight ❑
Closed tight ❑
TEST GAUGE USED:Make / Model �1 �1�$f ;j � SN: AQ�alibration Date:-,0?,
Remarks:
The above is certified to be true at the time of testing j
Firm Name CHARTER FIRE PROTECTION.INC, Certified Tester Gad /iV
Firm AddregS-P.O. BOX 4578 Cert. Tester No. 11z z
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.
Coppeli, TX 75019
04418