NO PERMIT NUMBER CROSS CONNECTION SPECIALISTS
CERTIFICATION OF RE-CLAIMED WATER SYSTEMS 4f'"-• -"`4 BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS .�j-_ INSTALLATION-REPAIRS-TESTING-CERTIFICATION
*BACKFLOW PREVENTION SPECIALISTS, INC.
LICENSED CONTRACTOR C.C.L.#427326 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 Stevens Creek,Cupertino near Wolfe
MAILING ADDRESS M&B Plumbing CONTACT David
1440 S.Main St TEL# 262-4800
Milpitas,CA 95035
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts 009M2 RP 3" 187899
INTERNAL Cl TAG LOCATION OF DEVICE mtr#62011051 domestic main
EXTERNAL
t
IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOXb PASS FAIL❑
• REDUCED PRESSURE DEVICES
PRESSURE TYPE
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECKVALVE CHECKVALVE PRESSURE/RELIEF
NOA NO.2 VALVE AIR INLET CHEO(VALVE
CLOgTIIGHT I). CLOSED TIGHT g OPENED AT / (LBS. OPENED AT_LBS CLOSED TIGHT ❑
INITIAL #Ibs. / �D� #Ibs. #LBS #LBS.
TEST OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKED Cl LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT❑
TEST #LOS #LBs ILBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TES Y CERTIFIED TESTER NO.48 DATE 10-10-02
MO. DAY YR.
• REPAIRED BY DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.