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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