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NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMSw CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT ., INSTALLATION-REPAIRS-TESTING-CERTIFICATION S/roYd���0• OBACKFLOW PREVENTION SPECIALISTS, I..N1C, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (BDO)464-FLOW(3569) F7,1 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 FAX)269- �� 1522-A DAY AVE.,SAN MATEO CA 94403 II -- � = SERVICE ADDRESS 10555 Rid eview Ct.,Cupertino JAN7, o7QD4 MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773-6220 Buffalo Grove, U,60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER wilkins 975XL RP 2° 1214403 INTERNAL ® TAG LOCATION OF DEVICE behind bldg 6 cooling tower EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PAS FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF NO.1 NO.2 VALVE AIR INLET CHECK VALVE CLOS TIGHT}"" CLOSEOTIGHT, — OPENEDATVE� tt//�LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL #lbs. #lbs. #LBS #USE. 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 Cl OPENEDAT_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST #LBS #LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY ��-� - - � CERTIFIED TESTER N0, 2656 DATE 12-10-03 , MO. DAY 'YR. • REPAIRED BY DATE M FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS _ - CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS I NSTALLATION-REPAI RS-TESTING-CERTIFICATION Sitiratta�9"O' 'OBACKFLOW 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 10555 Rid eview Ct.,Cupertino I I �I�jvgj 3 MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Da a JAN 2 0 2004 801 Asbury Dr TEL# 773-62 03Y: Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975XL RP 1„ 1207396 INTERNAL .1 � TAG LOCATION OF DEVICE mechanical mom#61182 EXTERNAL ❑ IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT & CLOSED TIGHT— OPENEDATZ-�' LES. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #Ibs. la, Z #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 ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LES OPENEDAT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO, DATE MO. DAY YR. . 1 CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ��� BACKFLOW PREVENTION VALVE EXPERT �j � INSTALLATION-REPAIRS-TESTING-CERTIFICATION *BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)iriv�.p-� 3750.E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 L 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269.2650 JAN 2 0 70ne SERVICE ADDRESS 10555PidgeviewCt,Cupertino C �; MAILING ADDRESS Tech Facility Siemens Bldg atm:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773-6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975XL RP 11. 1661619 INTERNAL ® TAG LOCATION OF DEVICE above boiler bldg 13 boiler/chller room EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS FAIL❑ REDUCED PRESSURE DEVICES ' ` PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHEOKVALVE CHECK VALVE PRESSURE/RELIEF N0.7 N0.2 VALVE AIR INLET CHECK VALVE cLOSEDTIGHTP CLOSED TIGHT'— OPENEDAT�ZLBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL #lbs. #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 ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENEDAT_LBS OPENED AT_LBS t LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER No.2656 DATE 12-10-03 MO. DAY YR. •REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS 4 °°°//////���... CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING %ACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3569r� 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 FAX)269-2600 ( ) -.� 1522-A DAY AVE.,SAN MATEO CA 94103 JAN 20Z0 SERVICE ADDRESS 10555 Rid eview Ct.,Cu rlino/X-Stevens Creek MAILING ADDRESS Tech Facility Bldg attn: Accounts Payable attn: Accounts Payable CONTACT Dom' y' _--_ 801 Asbury Dr TEL# 773-6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825Y RP 2° A132978 INTERNAL ® TAG LOCATION OF DEVICE irrigation bldg 13 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS FAIL❑ • 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 � CLOSER TIGHT I® CLOSED TIGHT 13 OPENEDAT"-3" LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL 9 b #lbs. #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT TEST #LBS #LBS tLBS THE ABOVE REPORT 15 CERTIFIED TO BE TRUE INITIAL TEST BY IA"-t CERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR.