BackflowCROSS CONNECTION SPECIALISTS
CERTIFICATION OF RE- CLAIMED WATER SYSTEMS :�"`ae BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS, INSTALLATION - REPAIRS - TESTING - T
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BACKFLO
W PREVENTION ? SPECIALISE S�, NC.
LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 4
3750 -E CHARTER PARK DR., SAN JOSE CA 95136 -1356 FAX AX 269-2600 9
1522-A DAY AVE. SAN MATEO CA 94403 FAX (408) 269 --
2650
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LJ
Y
SERVICE ADDRESS 19200 Stevens Creek Blvd. , Chpertino/X -Wolfe Rd
MAILING ADDRESS Cyprcss Properties, Inc
2191 E Bayshore Rd., Ste. 220
Palo Alto, CA 94303
MANUFACTURER MODEL NUMBER TYPE
Feboo 825Y RP
INTERNAL ® TAG
EXTERNAL ❑
CONTACT COnniC
TEL# (650) 424 -8383 xl
SIZE SERIAL NUMBER
2° AD3703
LOCATION OF DEVICE inigalion next to Bldg
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX C3 PASS FAIL❑
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST DV /� •�� _.....CERTIFIED TESTER NO. 9815 DATE 10 -08 -03 _.
-. ... _._... _ MO. DAY YR.j
• REPAIRED BY
DATE . ,.. r ,,
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.
REDUCED PRESSURE DEVICES ... .I_u
...... ...- PRESSURE TYPE......
VACUUM BREAKERS'':'
' DOUBLE CHECK VALVES
RPP VALVES
DIFFERENTIAL
CHECK VALVE
CHECK VALVE
AIR INLET
CHECK VALVE
PRESSURE /RELIEF
'
' NOA _
NO.2
VALVE
.�
TIGHT ❑
CLOSED TIGHT
CLOSED TIGHT U0
i`
OPENED AT .2'9LBS.
OPENEDAT_LBS
CLOSED
INITIAL
L�
#Ibe. D' 7
Nlbc.
#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
CLOSED TIGHT ❑
CLOSED TIGHT ❑
CLOSED TIGHT ❑
FINAL
OPENED AT
OPENED AT LBS
TEST
#LBS
ALBS
_LBS
#LBS
r0.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST DV /� •�� _.....CERTIFIED TESTER NO. 9815 DATE 10 -08 -03 _.
-. ... _._... _ MO. DAY YR.j
• REPAIRED BY
DATE . ,.. r ,,
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.