NO PERMIT NUMBER (3) CERTIFICATION OF RE-CLAIMED WATER SYSTEMS g► '~ p'°`�'+q, CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS _,, BACKFLOW PREVENTION VALVE EXPERT
� INSTALUITION-REPAIRS-TESTING-CERTIFICATION
'*BACKFLOW PREVENTION SPECIALISTS, INC,
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3589)
3750-E CHARTER PARK DR.,SAN JOSE CA 95136.1356 (408)2'69 269.2880
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX
r 8 zoos
SERVICE ADDRESS Btwn Wolfe&Finch on Stevens Creek AU6
MAILING ADDRESS J.Flores Construction Co. CONTACT Joe
4229 Mission St. TEL# (415)337-2934
San Francisco,CA 94112
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Ames 2000B DC 3/4" 42070
INTERNAL ❑ TAG LOCATION OF DEVICE fire by pass mtr#30004683
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX® PASS 0'FAILO
• REDUCED PRESSURE DEVICES
PRESSURE TYPE
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECK VALVE CHECKVALVE PRESSURE I RELIEF
NOA NO.2 VALVE AIR INLET CHECK VALVE
CLOSED TIGHT ZV CLOSED TIGHT OPENEDAT_LBS. OPENEDAT__LBS CLOSED TIGHT ❑
INITIAL S lbs.� 1� #Ibs.P.a *LBS 0 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 C1 CLOSED TIGHT ❑ OPENED AT_ OPENED AT_LBS CLOSED TIGHT❑
TEST #LBS #LBS tLBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BYy/ �/ CERTIFIED TESTER N0. 10220 DATE 8-03-05
MO. DAY YR.
• REPAIRED BY DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.