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BACKFLOWCROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMSfir CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS,> 11 BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION Spm q,�e. %ACKFLOW 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 FAX (408) 269.2650 3608 FERNWOOD ST., SAN MATEO CA 94403 DIFFERENTIAL • SERVICE ADDRESS 20450 Stevens Creek Blvd., Cupertino/X-DeAn2a Blvd. MAILING ADDRESS Prometheus 20400 Stevens Creek Blvd., #245 Cupertino, CA 95014 MANUFACTURER MODEL NUMBER TYPE Watts 009M2QT RP INTERNAL ® TAG EXTERNAL ❑ CONTACT Bob TEL# 408410-6517 SIZE SERIAL NUMBER 1„ 186607 LOCATION OF DEVICE Roof Boiler Makeup Water IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX C3 PASS® FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 1/21/05 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE/RELIEF VALVE AIR INLET CHECKVALVE NOA NO.2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT 3.0 LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL # lbs. 8.8 # lbs. #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 Cl CLOSED TIGHT❑ OPENED AT OPENED AT LBS TEST #LBS #LBS _LBS _ #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 1/21/05 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS BAS .. BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS•Ii INSTALLATION -REPAIRS -TESTING -CERTIFICATION ftACKFLOW 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 3608 FERNWOOD ST., SAN MATEO CA 94403 FAX (408) 269-2650 • • SERVICE ADDRESS 20450 Stevens Creek Blvd., Cupertino/X-DeAn2a Blvd MAILING ADDRESS Prometheus CONTACT Bob 20400 Stevens Creek Blvd., #245 TEL# 408410-6517 Cupertino, CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 805Y DC I„ R6070 INTERNAL ® TAG LOCATION OF DEVICE Roof Chilled Water Makeup Line EXTERNAL ❑ OG o-,✓ Cfi.%/off lvt-f ���S.:e../�' .� e a -v Z� IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX ❑ PASS® FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY �- CERTIFIED TESTER NO. 2656 DATE 1/21/05 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. MO. DAY YR. DATE MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECKVALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE N0.1 N0.2 CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT_LBS. OPENED AT_LBS CLOSEDTIGHT ❑ INITIAL # IUs. 1.4 # IDs. 1.8 #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 ❑ OPENED AT LBS OPENED AT LBS - TEST I # LBS #LBS _ _ # LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY �- CERTIFIED TESTER NO. 2656 DATE 1/21/05 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. MO. DAY YR. DATE MO. DAY YR.