Loading...
NO PERMIT NUMBER (3) CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION 16 BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)484-FLOW(3589) 3750-E CHARTER PARK DR.,SAN JOSE CA 95138.1356 (408)269-2600 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-26 SERVICE ADDRESS 20803 Alves Dr.,Cu rtino/X-N De Anza Blvd toot 0 2i AON MAILING ADDRESS Northwest YMCA CONTACT Pau -$� 20803 Alves Dr TEL# 257-7160 Cupertino,CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Willdns 950DA DCDA 61' D08028 INTERNAL ❑ TAG LOCATION OF DEVICE EXTERNAL ❑ CEIVED NOV 2 0 2002 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX PASS AIL REDUCED PRESSURE DEVICES PRESSURE TYPE -�.. DOUBLE CHECK VALVES VACUUM BREAKERS i r ._ ._.. .... RPP VALVES. .. -DIFFERENTIAL,,. CHECK VALVE CHECKVALVE PRESSURE I RELIEF - N0.1 N0.2 VALVE AIR INLET CHECK VALVE 4 - CLO E • CLOSED�1 OPENED AT_LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #Iba. #lbs. • #LBS CLBS. 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 ❑ OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST 9LBS ALBS 1LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE _... ._ .... .�.:.. ... 8743 INITIAL TE T'BV CERTIFIED TESTER NO. 'GATE 11-11-02 _. MO. DAY YR.' � REPAIREDBY ._ - _ . ... . DATE ' FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS �y :',.�4 CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT . �� INSTALLATION-REPAIRS-TESTING-CERTIFICATION '� 4 Shy 9se BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3569) 3750-E CHARTER PARK DR.,SAN JOSE CA 95136.1356 (408)269-2600 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 20803 Alves Dr.,Cupertino/X-N De Amu Blvd MAILING ADDRESS Northwest YMCA CONTACT Paul 20803 Alves Dr TEL# 257-7160 Cupertino,CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER WiRdns 950DA DCDA 6° D08032 INTERNAL ❑ TAG LOCATION OF DEVICE EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS AIL❑ • REDUCED PRESSURE DEVICES _ PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE ,- CLOSED TIGHT CLOSED TIGHT OPENEDAT_LBS. OPENEDAT_LBS CLOSED TIGHT ❑ '- INITIAL #Lbs. #lbs.� #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED Cl REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TESTOPENED AT_LBS OPENED AT_LBB #LBS #LBS IL85 THE ABOVE REPORT IS CERTIFIED TO BE TRUE .. INITIALTEST / .CERTIFIED TESTER NO.8743 DATE 11-11-02 MO. DAY_ YR. REPAIRED BY 0147E FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. ""° i>rwy,,,,_ CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS -, BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ��p///, INSTALLATION-REPAIRS-TESTING-CERTIFICATION S�r�ats�9sa . BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3589) y 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 . 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 20803 Alves Dr.,Cupertino/X-N De Anza Blvd MAILING ADDRESS Northwest YMCA CONTACT Paul r. 20803 Alves Dr TEL# 257-7160 Cupertino,CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 375 — RP 4" L00909 INTERNAL ❑ TAG LOCATION OF DEVICE EXTERNAL ❑ 1 0 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS AIL❑ • REDUCED PRESSURE DEVICES \\ PRESSURE TYPE `F DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGH CLOSED TIGH OPENEDAT�LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #tbs. f7 f0tbs. *LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND f,h'�. .• MATERIALS USED FINAL CLOSED TIGHT CLOSED TIGHT ❑ OPENEDA7_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST #LBS #LBS /LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIALTEBY -�CERTIFIED TESTER NO.8743 DATE ll-ll-02 ST MO. DAY YR. --•REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. r� +fir