NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS pcp°" CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS , *r BACKFLOW PREVENTION VALVE EXPERT
CALIFORNIA (800)464-FLOW(3569) •
INSTALLATION-REPAIRS-TESTING-CERTIFICATION
• LOCAL(408)269-2600swliats LICENSED CONTRACTOR C.C.L.#427328
FAX(408)269-2650 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356
BACKFLOW PREVENTION SPECIALISTS, INC.
MAILING/OWNER Drain Works SERVICE Drain Works
Address ADDRESS
19871 Graystone Way 7178 Blue Hill Dr
San Jose,CA.95120 Cupertino,CA 95014
CONTACT:John Sachs TEL# 408-315-6967
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts 009 4M2" 09731
NEW INSTALLATION:E] REPLACEMENT:
REPLACEMENT DEVICE INFORMATION
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
LOCATION OF DEVICE
INTERNAL ❑ METER 31868708
EXTERNAL® TAG# -
Hazard Type:
• REDUCED PRESSURE DEVICES PRESSURE TYPE
Shutoff Valves
DOUBLE CHECK VALVES VACUUM BREAKERS
DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
AIR INLET CHECK VALVE
N0.1 N0.2VALVE
#1 #2
CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT_LBS. OPENED AT—LBS CLOSED TIGHT El CLOSED TIGHT❑ ❑
INITIAL p Ibs. #Ibs. LEAKED
TEST OPENED UNDER 2.0 OPENED UNOER 1.0 #LBS. ❑ ❑
R DID NOT OPEN❑
LEAKED LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED ,�-J/
FINAL CLOSED TIGHT CLOSED TIGHT py- OPENED AT ILBS DPENED AT pLB CLOSED TIGHT❑
CLOSED TIGHT
TEST #LBS�� aLBS pL85
Comments: '
THE ABOVE REPORT IS CERTIFIED TO BE TRUE /yam/`
ITIAL TEST BY
CERTIFIED TESTER NO. IM457e DATE 512311;17 FAILS
MO. DAY YR.
REPAIRED BY DATE 4�
po�`
PASS
FINAL TEST B CERTIFIED TESTER NO. 14f&a DATE FAIL
Y YR.