NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS $� r CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS �+' BACKFLOW PREVENTION VALVE EXPERT
P INSTALLATION-REPAIRS-TESTING-CERTIFICATION
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'*BACKFLOW PREVENTI N� PfQ7ZLISTS, INC.
LICENSED CONTRACTOR C.C.L.#427328 SEP 2 U 2006 CALIFORNIA (800)464-FLOW(3569)
3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600
FAX(408)269-2650
SERVICE ADDRESS 20421 Pacifica Dr.Cupertino/x-S De Anza Blvd
MAILING ADDRESS California Dental Arts CONTACT Bette
20421 Pacifica Dr.Cupertino/x-S De Anza Blvd TEL# 408-777-4653
Cupertino,CA 95014
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Hersey FRP-11 Q P 2•• 161204
INTERNAL ❑ TAG LOCATION OF DEVICE in front of building by sidewalk
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX PAS FAIL❑
• REDUCED PRESSURE DEVICES
PRESSURE TYPE Shutoff Valvas
DOUBLE CHECK VALVES VACUUM BREAKERS
DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
AIR INLET CHECK VALVE
N0.1 N0.2 VALVE
#1 #2
CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT—LBS. OPENED AT LBS CLOSED TIGHT C1 CLOSED TIGHT ❑
INITIAL #Ihs. #tbs. OPENED UNDER 1.0 N LBS. LEAKED ❑ 11TEST OPENED UNDER 2.0 OF DID NOT OPEN❑
LEAKED LEAKED ❑ t,.., OR DID NOT OPEN Cl LEAKED ❑
REPAIRS
AND
MATERIALS S
USED
FINAL CLOSED TIGHT CLOSED TIGH OPENED AT-7-18 LBS OPENED AT LBI CLOSED TIGHT❑
TEST gLES /'!J #LBS CLOSED TIGHTJ,G
#LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST V CERTIFIED TESTER N0, 8743 DATE 08-31-06
MO. DAY YR.
- REPAIRED BY DATE �'3pv�IV�L J�
FINAL TES BV '� CERTIFIED TESTER NO. V7 `✓ DATE gra' ��v1�
MO. DAV YR.