NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS fatiE 'y CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
I N STALLATION-R EPAI R S-TESTING-CERTIFICATIO N
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%ACKFLOW PREVENTION SPECIALISTS, INC.
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)484-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 22690 San Juan Rd.,Cupertino/X-Foothill Blvd
MAILING ADDRESS Tanya Kuitka CONTACT Alex
22690 San Juan Rd TEL# 746-9900x12
Cupertino,CA 95014
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts 909M1 RP 11/2" 214445
INTERNAL ❑ TAG' LOCATION OF DEVICE in well enclosure area on hill work zoncZ
EXTERNAL ® prop#41-049-6896-1 acct#301802 mtr#30154602
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
N0.1N0.2
VALVE AIR INLET CHECK VALVE
CLOSED TIGHT ❑ CLOSED TIGHT Cl OPENEDAT_LBS. OPENEOAT_LBS CLOSEDTIGHT ❑
INITIAL 4Ibs. 9Ibs. #LBS 0 LBS,
TEST ((�� OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKppppEDob LEAKED, OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS C�J
AND - J
MATERIALS
USED
FINAL CLOSE.0./Tt�aHT CLOSED TIGHT C!O
1_ OPENED AT!LBS OPENED AT_LBS CLOSED TIGHT❑
TEST 0Las ALBS SLBS
THE ABOVE REPORT I RTIFIE TO BE TRUE -
1
F
INITIAL TEST B CERTI-IED TESTER NO. - .-.DATE "t V
.MO., DAY YR,;
•REPAIRED BV DATE
FINAL TEST BY CERTIFIED TESTER NO. �--L (/ DATE ) </ 'V
MO. DAY YR.