NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
�—��- BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ��j.^ . . f INSTALLATION-REPAIRS-TESTING-CERTIFICATION
BACKFLOW PREVENTION SPECIALISTS, INC.
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3589)
3750-E CHARTER PARK DR.,SAN JOSE CA 95136.1356 (408)269-2600
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650
SERVICE ADDRESS 10300 S.Blaney Ave.,Cupertino/X-Blaney Ct.&La MarDr.
MAILING ADDRESS Portal Elementary CONTACT Michael
10300 S.Blaney Ave. TEL# 873-7140
Cupertino,CA 95014 �'
MANUFACTURER MODEL NUMBER TYPE - ..� I �` L MBER
-- Willdns 375 - RP 4„ AUG 3 1 2gp394
INTERNAL ❑ TAG LOCATION OF DEVICE mtr4 90310494
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS FAIL❑
- REDUCED PRESSUREbEVICES ��� , . �-- � " "
PRESSURE TYPE' '�
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
N0.1 N0.2.
VALVE AIR INLET CHECKVALVE
CLO II HT ❑ CLOSED TIGHT If OPENED AT��BS. OPENED AT_LBS CLOSED TIGHT ❑
INITIAL #Ibs. #Ibs. #LBS #LBS.
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 O CLOSED TIGHT❑
TEST #1_88 #LBS OPENED AT UBS OPENEDAT_LBS It LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BYpL7T / - LZ -��• CERTIFIED TESTER NO. 9815 `°"`' DATE'g-18-04
REPAIRED BY "' - -
DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.