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BACKFLOWCERTIFICATION OF RE-CLAIMED WATER SYSTEMS fA'1tlACROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSv BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 464-FLOW (3569 ,.,, y t 3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 (408) 269-2600 Y=��S -; ' ) 1522-A DAY AVE., SAN MATEO CA 94403 Cal Water Lost Altos FAX (408) 269-2650 rn� qr r1 L SERVICE ADDRESS 10023 De Anza MAILING ADDRESS Service Station Systems, Inc. 680 Ouinn Ave Creek San Jose, CA 95112 MANUFACTURER MODELNUMBER TYPE Febco 825YA RP INTERNAL ® TAG EXTERNAL ❑ CONTACT Joan TEL# 938-7112 LOCATION OF DEVICE main water Noy SIZE SERIAL NUMBER 11/2" A015001 ion Chevron mtrA 13685013 IF DEVICE IS ANEW 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 I RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CL SE� D TIGHT ❑ CLOSED TIGHT OPENED AT� LBS. OPENEDAT _ LBS CLOSED TIGHT ❑ INITIAL # h. A 9Ihs. #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 ❑ CLOSED TIGHT ❑ TEST #LBS I #LBS OPENEDAT_LBS OPENED AT_LES #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY _ P(L_I ' '�'IG1Y d,PA�'Pi CERTIFIED TESTER NO.ttI6 10566 DATE 11-0 -OS MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS A'� BACKFLOW PREVENTION VALVE EXPERT �l INSTALLATION -REPAIRS -TESTING -CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (80 )r484y 9�T I 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 (408) 269-2600 1522-A DAY AVE.. SAN MATEO CA 94403 Cal Water Lost Altos FAX (408) 269-265, Nl(j\J ® 2��5 • SERVICE ADDRESS 10023 De Anza MAILING ADDRESS Service Station Systems, Inc Creek 680 Quinn Ave San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPE Watts 007M I QT DC INTERNAL ❑ TAG EXTERNAL LOCATION OF DEVICE mlr# CONTACT Joan TEL# 938-7112 SIZE SERIAL NUMBER 1 1/2" 43117 Chevron main water IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[:] PAS SAI FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CLOSED TIGHT I[1 CLOSED TIGHT OPENEDAT_LBS. OPENEOAT_LBS CLOSEDTIGHT ❑ INITIAL # Ibs, 1.8 # lbs. 1.11 #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 ❑ CLOSED TIGHT ❑ TEST OPENED AT _ LBS OPENED AT _ LBS #LBS #LBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE 13 INITIALTESTBY�� (jWOM &d 64L CERTIFIED TESTER NO.� I Oai; DATE 11-0.4-05 MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. ��//�. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS T�� BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION -REPAIRS -TESTING -CERTIFICATION '*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) 269.2850 • SERVICE ADDRESS 10023 De Anza Blvd., Cupertino/X-Stevens Creek MAILING ADDRESS Service Station Systems, Inc. CONTACT 680 Quinn Ave TEL# 938-7112,.E San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERVAL NUMBER Febco 825YA RP 11/2" A015001 INTERNAL ® TAG LOCATION OF DEVICE main water irrigation Chevron mtr# 13685013 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS)O FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE NOA NO.2 o� CLOSED T16 TIGHT. CLOSED TIGHT �. OPENED AT � LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL F tbs. f9 0 tbs. *LBS Is 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 ❑ CLOSED TIGHT Cl TEST •LBS tLBS OPENED AT LBS _ _ OPENED AT LBS /lBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10220 DATE 10-19-04 MO. DAY YR. Lam' CERTIFIED TESTER NO. DATE MO. DAY YR. _�I� " CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS 45'""' BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION -REPAIRS -TESTING -CERTIFICATION '�%hrliia'9.e•. %ACKFLOW 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 44 1622-A DAY AVE., SAN MATEO CA 903 FAX (408) 269-2650 • SERVICE ADDRESS 10023 De Anna Blvd., Cupertino/X-Stevens Creek MAILING ADDRESS Service Station Systems, Inc. CONTACT Joan 680 Quinn Ave TEL# 938-7112 San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPES SIZE SERIAL NUMBER ti Watts 007MIQT 14p-p, 11/21, 43117 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 13685013 Chevron main water EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX Cl PASS FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE I RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CLO EFIGHT CLOSED TIGHT OPENED AT _ LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL Otbs. . 6tbs. - #LB6 #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 ❑ CLOSED TIGHT ❑ TEST #LBS OLDS OPENED AT_LBS OPENED AT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY . REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO, 10220 DATE CERTIFIED TESTER NO. DATE 10-19-04 MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ,g�u6�O0M CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS _r , Ir BACKFLOW PREVENTION VALVE EXPERT &��I� INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569) `.� LOCAL (408) 269-2600 FAX (408) 269-2650 Spky� qwe• LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 OBACKFLOW PREVENTION SPECIALISTS, INC. MAILING / OWNER Service Station Sy: Address 680 Quinn Avenue San Jose, CA. 95112 6AY. CONTACT: Michelle MANUFACTURER MODELNUMBER Watts 007M I QT NEW INSTALLATION: REPLACEMENT: REPLACEMENT DEVICE INFORMATION MANUFACTURER MODEL NUMBER INTERNAL ❑ METER# 13685013 EXTERNAL ® TAG # Hazard Type: Main water • Chevron #95954 10023 S DeAnza Blvd. Cupertino, CA. 95014 -938-7102 . TYPE SIZE SERIAL NUMBER DC 1 1 /2" 43117 TYPE SIZE SERIAL NUMBER LOCATION OF DEVICE ' REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE #1 #2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT_ LBS. OPENED AT LEE CLOSED TIGHT El CLOSED TIGHT® 59 INITIAL # Ibs. 1.8 # Ibs. 1.8 OPENED UNDER 1.0 #LBS. LEAKED ❑ TEST OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT ❑ TEST OPENED AT_#LBS PENED AT_pLB CLOSED TIGHT❑� pLBS pLBS pLBS Comments: THE ABOVE INITIAL TEST BY •REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO, 10466 DATE CERTIFIED TESTER NO. PASS DATE 06/01/07 FAIL ❑ MO. DAY YR. DATE PASS ❑ FAIL ❑ MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ,��c6�°k" CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'i" , -i" BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569)•�� LOCAL (408) 269-2600 g ���, LICENSED CONTRACTOR C.C.L.# 427328 FAX (408) 269-2650 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 41BACKFLOW PREVENTION SPECIALISTS, INC. MAILING/OWNER Service Station Systems, Inc. ^!" ER ICE Chevron #95954 Address 680 Quinn Avenue I A, ADDRESS 10023 S DeAnza Blvd. n San Jose, CA. 95112 AUl] LOOT 1 Cupertino, CA. 95014 CONTACT: Michelle I TEL# 408-938-7102 MANUFACTURER MODELNUMBER Febco 825YA TYPE SIZE SERIAL NUMBER RP 11/2" A015001 VEW INSTALLATION: ❑ REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODEL NUMBER TYPE SIZE - SERIAL NUMBER INTERNAL ® METER# 13685013 EXTERNAL ❑ TAG # Hazard Tvoe: • LOCATION OF DEVICE Main Water Irrigation Chevron REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE #1 #2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT 2.6 LBS. OPENED AT LBS CLOSED TIGHT ❑ CLOSED TIGHT❑ INITIAL # lbs. 8.2 # lbs. # LBS LEAKED ❑ ❑ TEST OPENED UNDER 2.0 OPENED UNDER 1.0 R DID NOT OPEN ❑ LEAKED O LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST OPENED AT_kLBS PENED AT_kLB CLOSED TIGHT ❑❑ #LBS #LBS # LBS Comments: THE ABOVE INITIAL TEST BY •REPAIRED BY CERTIFIED TESTER NO. 10466 DATE FINAL TEST BY CERTIFIED TESTER NO. PASS DATE06/01/07 FAIL ❑ MO. DAY YR. PASS ❑ DATE FAIL ❑ MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS �Fra#"ery4 CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS CALIFORNIA 'i' , 'I' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION (800) 464-FLOW (3569) Y• LOCAL (408) 269-2600 FAX 1408) 269-2650 S�yt. LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 BACKFLOW PREVENTION SPECIALISTS, INC. MAILING / OWNER Service Station Systems, Inc. Address 680 Quinn Avenue San Jose, CA. 95112 CONTACT: Michelle SERVICE Chevron #95954 ADDRESS 10023 S DeAnza Blvd. Cupertino,,CA. 95014 TEL# 408-938-7102 MANUFACTURER MODEL NUMBER TYPE Febco 825YA, RP NEW INSTALLATION: ❑ REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODELNUMBER TYPE INTERNAL ® METER# 13685013 EXTERNAL ❑ TAG # Hazard Tvoe: • LOCATION OF DEVICEMain Water SIZE cUU( SERIAL NUMBER 11/2" A015001 SIZE SERIAL NUMBER n Chevron REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET PRESSURE / RELIEF NO.1 N0.2 VALVE CHECK VALVE #1 #ryry2t� CLOSED TIGHT CLOSED TIGHT OPENED AT j- (0 LBS. OPENED AT_ LBS CLOSED TIGHT❑ CLOSED TIGHT❑ {y INITIAL # lbs. R.9 # lbs. LEAKED ❑ ❑ OPENED UNDER 1.0 # LBS. TEST OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST a LEIS NLBS OPENED AT #LBS _ OPENED AT #LB CLOSED TIGHT ❑ ❑ p LBS Comments: THE ABOVE REP S CERTIFI 0 BE lITIAL TEST BY REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10466 DATE CERTIFIED TESTER NO. DATE 06/01/07 MO. DAY YR. DATE MO. DAY YR. PASS FAIL ❑ F❑ ❑ CERTIFICATION OF RE-CLAIMED WATER SYSTEMS R"ewy4 CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'I' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569) • LOCAL (408) 269-2600 �Z 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 Service Station Systems, Inc. Address 680 Quinn Avenue San Jose, CA. 95112 CONTACT: Michelle MANUFACTURER MODEL NUMBER Watts 007MIQT NEW INSTALLATION: REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODELNUMBER INTERNAL ❑ METER 13685013 EXTERNAL ® TAG q Hazard Type; Main water • SERVICE Chevron#95954 ADDRESS 10023 S DeAnza Blvd Cupertino, CA. 95014 TEL# 408-938-7102 TYPE SIZE SERIAL NUMBER DC 1 1 /2" 43117 TYPE SIZE SERIAL NUMBER LOCATION OF DEVICE 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 N0.2 VALVE #1 grt2f CLOSED TIGHT ai CLOSED TIGHT ® OPENED AT_LBS. OPENED AT_LES CLOSED TIGHT❑ CLOSED TIGHT@ Qd INITIAL # Its. �� 5 # lbs. /+U LEAKED Cl ❑ TEST OPENED UNDER I.O q LBS. OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOBEDTIGHT❑ TEST pLBS OPENED AT_#LBS PENED AT MLB CLOSED TIGHT LID gLBS ALBS Comments: THE ABOVE REP �ITIAL TEST BY REPAIRED BY FINAL TEST BY PASS TESTER No. 10466 DATE 06/01/07 FAIL MO. DAY YR. DATE CERTIFIED TESTER NO. DATE PASS ❑ FAIL ❑ MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS fA'1tlACROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSv BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 464-FLOW (3569 ,.,, y t 3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 (408) 269-2600 Y=��S -; ' ) 1522-A DAY AVE., SAN MATEO CA 94403 Cal Water Lost Altos FAX (408) 269-2650 rn� qr r1 L SERVICE ADDRESS 10023 De Anza MAILING ADDRESS Service Station Systems, Inc. 680 Ouinn Ave Creek San Jose, CA 95112 MANUFACTURER MODELNUMBER TYPE Febco 825YA RP INTERNAL ® TAG EXTERNAL ❑ CONTACT Joan TEL# 938-7112 LOCATION OF DEVICE main water Noy SIZE SERIAL NUMBER 11/2" A015001 ion Chevron mtrA 13685013 IF DEVICE IS ANEW 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 I RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CL SE� D TIGHT ❑ CLOSED TIGHT OPENED AT� LBS. OPENEDAT _ LBS CLOSED TIGHT ❑ INITIAL # h. A 9Ihs. #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 ❑ CLOSED TIGHT ❑ TEST #LBS I #LBS OPENEDAT_LBS OPENED AT_LES #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY _ P(L_I ' '�'IG1Y d,PA�'Pi CERTIFIED TESTER NO.ttI6 10566 DATE 11-0 -OS MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS A'� BACKFLOW PREVENTION VALVE EXPERT �l INSTALLATION -REPAIRS -TESTING -CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (80 )r484y 9�T I 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 (408) 269-2600 1522-A DAY AVE.. SAN MATEO CA 94403 Cal Water Lost Altos FAX (408) 269-265, Nl(j\J ® 2��5 • SERVICE ADDRESS 10023 De Anza MAILING ADDRESS Service Station Systems, Inc Creek 680 Quinn Ave San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPE Watts 007M I QT DC INTERNAL ❑ TAG EXTERNAL LOCATION OF DEVICE mlr# CONTACT Joan TEL# 938-7112 SIZE SERIAL NUMBER 1 1/2" 43117 Chevron main water IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[:] PAS SAI FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CLOSED TIGHT I[1 CLOSED TIGHT OPENEDAT_LBS. OPENEOAT_LBS CLOSEDTIGHT ❑ INITIAL # Ibs, 1.8 # lbs. 1.11 #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 ❑ CLOSED TIGHT ❑ TEST OPENED AT _ LBS OPENED AT _ LBS #LBS #LBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE 13 INITIALTESTBY�� (jWOM &d 64L CERTIFIED TESTER NO.� I Oai; DATE 11-0.4-05 MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. ��//�. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS T�� BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION -REPAIRS -TESTING -CERTIFICATION '*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) 269.2850 • SERVICE ADDRESS 10023 De Anza Blvd., Cupertino/X-Stevens Creek MAILING ADDRESS Service Station Systems, Inc. CONTACT 680 Quinn Ave TEL# 938-7112,.E San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERVAL NUMBER Febco 825YA RP 11/2" A015001 INTERNAL ® TAG LOCATION OF DEVICE main water irrigation Chevron mtr# 13685013 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS)O FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE NOA NO.2 o� CLOSED T16 TIGHT. CLOSED TIGHT �. OPENED AT � LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL F tbs. f9 0 tbs. *LBS Is 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 ❑ CLOSED TIGHT Cl TEST •LBS tLBS OPENED AT LBS _ _ OPENED AT LBS /lBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10220 DATE 10-19-04 MO. DAY YR. Lam' CERTIFIED TESTER NO. DATE MO. DAY YR. _�I� " CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS 45'""' BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION -REPAIRS -TESTING -CERTIFICATION '�%hrliia'9.e•. %ACKFLOW 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 44 1622-A DAY AVE., SAN MATEO CA 903 FAX (408) 269-2650 • SERVICE ADDRESS 10023 De Anna Blvd., Cupertino/X-Stevens Creek MAILING ADDRESS Service Station Systems, Inc. CONTACT Joan 680 Quinn Ave TEL# 938-7112 San Jose, CA 95112 MANUFACTURER MODEL NUMBER TYPES SIZE SERIAL NUMBER ti Watts 007MIQT 14p-p, 11/21, 43117 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 13685013 Chevron main water EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX Cl PASS FAIL❑ REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE I RELIEF VALVE AIR INLET CHECKVALVE N0.1 N0.2 CLO EFIGHT CLOSED TIGHT OPENED AT _ LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL Otbs. . 6tbs. - #LB6 #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 ❑ CLOSED TIGHT ❑ TEST #LBS OLDS OPENED AT_LBS OPENED AT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY . REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO, 10220 DATE CERTIFIED TESTER NO. DATE 10-19-04 MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ,g�u6�O0M CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS _r , Ir BACKFLOW PREVENTION VALVE EXPERT &��I� INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569) `.� LOCAL (408) 269-2600 FAX (408) 269-2650 Spky� qwe• LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 OBACKFLOW PREVENTION SPECIALISTS, INC. MAILING / OWNER Service Station Sy: Address 680 Quinn Avenue San Jose, CA. 95112 6AY. CONTACT: Michelle MANUFACTURER MODELNUMBER Watts 007M I QT NEW INSTALLATION: REPLACEMENT: REPLACEMENT DEVICE INFORMATION MANUFACTURER MODEL NUMBER INTERNAL ❑ METER# 13685013 EXTERNAL ® TAG # Hazard Type: Main water • Chevron #95954 10023 S DeAnza Blvd. Cupertino, CA. 95014 -938-7102 . TYPE SIZE SERIAL NUMBER DC 1 1 /2" 43117 TYPE SIZE SERIAL NUMBER LOCATION OF DEVICE ' REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE #1 #2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT_ LBS. OPENED AT LEE CLOSED TIGHT El CLOSED TIGHT® 59 INITIAL # Ibs. 1.8 # Ibs. 1.8 OPENED UNDER 1.0 #LBS. LEAKED ❑ TEST OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT ❑ TEST OPENED AT_#LBS PENED AT_pLB CLOSED TIGHT❑� pLBS pLBS pLBS Comments: THE ABOVE INITIAL TEST BY •REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO, 10466 DATE CERTIFIED TESTER NO. PASS DATE 06/01/07 FAIL ❑ MO. DAY YR. DATE PASS ❑ FAIL ❑ MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ,��c6�°k" CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'i" , -i" BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569)•�� LOCAL (408) 269-2600 g ���, LICENSED CONTRACTOR C.C.L.# 427328 FAX (408) 269-2650 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 41BACKFLOW PREVENTION SPECIALISTS, INC. MAILING/OWNER Service Station Systems, Inc. ^!" ER ICE Chevron #95954 Address 680 Quinn Avenue I A, ADDRESS 10023 S DeAnza Blvd. n San Jose, CA. 95112 AUl] LOOT 1 Cupertino, CA. 95014 CONTACT: Michelle I TEL# 408-938-7102 MANUFACTURER MODELNUMBER Febco 825YA TYPE SIZE SERIAL NUMBER RP 11/2" A015001 VEW INSTALLATION: ❑ REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODEL NUMBER TYPE SIZE - SERIAL NUMBER INTERNAL ® METER# 13685013 EXTERNAL ❑ TAG # Hazard Tvoe: • LOCATION OF DEVICE Main Water Irrigation Chevron REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE #1 #2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT 2.6 LBS. OPENED AT LBS CLOSED TIGHT ❑ CLOSED TIGHT❑ INITIAL # lbs. 8.2 # lbs. # LBS LEAKED ❑ ❑ TEST OPENED UNDER 2.0 OPENED UNDER 1.0 R DID NOT OPEN ❑ LEAKED O LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST OPENED AT_kLBS PENED AT_kLB CLOSED TIGHT ❑❑ #LBS #LBS # LBS Comments: THE ABOVE INITIAL TEST BY •REPAIRED BY CERTIFIED TESTER NO. 10466 DATE FINAL TEST BY CERTIFIED TESTER NO. PASS DATE06/01/07 FAIL ❑ MO. DAY YR. PASS ❑ DATE FAIL ❑ MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS �Fra#"ery4 CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS CALIFORNIA 'i' , 'I' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION (800) 464-FLOW (3569) Y• LOCAL (408) 269-2600 FAX 1408) 269-2650 S�yt. LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 BACKFLOW PREVENTION SPECIALISTS, INC. MAILING / OWNER Service Station Systems, Inc. Address 680 Quinn Avenue San Jose, CA. 95112 CONTACT: Michelle SERVICE Chevron #95954 ADDRESS 10023 S DeAnza Blvd. Cupertino,,CA. 95014 TEL# 408-938-7102 MANUFACTURER MODEL NUMBER TYPE Febco 825YA, RP NEW INSTALLATION: ❑ REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODELNUMBER TYPE INTERNAL ® METER# 13685013 EXTERNAL ❑ TAG # Hazard Tvoe: • LOCATION OF DEVICEMain Water SIZE cUU( SERIAL NUMBER 11/2" A015001 SIZE SERIAL NUMBER n Chevron REDUCED PRESSURE DEVICES PRESSURE TYPE Shutoff Valves DOUBLE CHECK VALVES VACUUM BREAKERS DIFFERENTIAL CHECK VALVE CHECK VALVE AIR INLET PRESSURE / RELIEF NO.1 N0.2 VALVE CHECK VALVE #1 #ryry2t� CLOSED TIGHT CLOSED TIGHT OPENED AT j- (0 LBS. OPENED AT_ LBS CLOSED TIGHT❑ CLOSED TIGHT❑ {y INITIAL # lbs. R.9 # lbs. LEAKED ❑ ❑ OPENED UNDER 1.0 # LBS. TEST OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST a LEIS NLBS OPENED AT #LBS _ OPENED AT #LB CLOSED TIGHT ❑ ❑ p LBS Comments: THE ABOVE REP S CERTIFI 0 BE lITIAL TEST BY REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10466 DATE CERTIFIED TESTER NO. DATE 06/01/07 MO. DAY YR. DATE MO. DAY YR. PASS FAIL ❑ F❑ ❑ CERTIFICATION OF RE-CLAIMED WATER SYSTEMS R"ewy4 CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'I' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION CALIFORNIA (800) 464-FLOW (3569) • LOCAL (408) 269-2600 �Z 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 Service Station Systems, Inc. Address 680 Quinn Avenue San Jose, CA. 95112 CONTACT: Michelle MANUFACTURER MODEL NUMBER Watts 007MIQT NEW INSTALLATION: REPLACEMENT: ❑ REPLACEMENT DEVICE INFORMATION MANUFACTURER MODELNUMBER INTERNAL ❑ METER 13685013 EXTERNAL ® TAG q Hazard Type; Main water • SERVICE Chevron#95954 ADDRESS 10023 S DeAnza Blvd Cupertino, CA. 95014 TEL# 408-938-7102 TYPE SIZE SERIAL NUMBER DC 1 1 /2" 43117 TYPE SIZE SERIAL NUMBER LOCATION OF DEVICE 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 N0.2 VALVE #1 grt2f CLOSED TIGHT ai CLOSED TIGHT ® OPENED AT_LBS. OPENED AT_LES CLOSED TIGHT❑ CLOSED TIGHT@ Qd INITIAL # Its. �� 5 # lbs. /+U LEAKED Cl ❑ TEST OPENED UNDER I.O q LBS. OPENED UNDER 2.0 R DID NOT OPEN ❑ LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOBEDTIGHT❑ TEST pLBS OPENED AT_#LBS PENED AT MLB CLOSED TIGHT LID gLBS ALBS Comments: THE ABOVE REP �ITIAL TEST BY REPAIRED BY FINAL TEST BY PASS TESTER No. 10466 DATE 06/01/07 FAIL MO. DAY YR. DATE CERTIFIED TESTER NO. DATE PASS ❑ FAIL ❑ MO. DAY YR.