NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSy�� BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION-REPAIRS-TESTING-CERTIFICATION
BACKFLOW PREVENTION SPECIALISTS, INC,
LICENSED CONTRACTOR C.C.L.#427328 Tr—_ V�
CALIFORNIA (800)464-FLOW:(3569)��p
1522 A DAY AVE. SAN MATEO CA 94403750-E CHARTER PARK DR.,SAN JOSE3 95136-1358 FAX 289-2800 I NOV x(15
FAX(408)269-2650 Imo,
SERVICE ADDRESS 20803 Alves Dr.,Cupertino/X-N De Anza Blvd '
MAILING ADDRESS Northwest YMCA CONTACT Paul
20803 Alves Dr. TEL# 351-2444
-1 Cupertino,CA 95014
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� MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Wilkins 950XL DC 3/4° 1114068
INTERNAL ❑ TAG LOCATION OF DEVICE mtr#56992071 fire by pass for SN D08032
EXTERNAL
IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS[)(FAIL❑
•, REDUCED PRESSURE DEVICES
-PRESSURE TYPE
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
NOA NO.2 VALVE AIR INLET CHECKVALVE
CLOSED TIGHT CLOSED TIGHT OPENED AT_LBS. OPENED AT_LBS CLOSED TIGHT ❑
INITIAL IIICs. ICs. J.8 #LBS IILBS.
TEST OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑
OPENED AT_LBS OPENED AT_LBS
TEST /LBS IILBS iLBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY Ci CERTIFIED TESTER NO. 10466 _. -.. DATE 11-16-05
_ MO. DAY YR.
'• REPAIRED BY DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.