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BACKFLOW CERTIFICATION OF RE-CLAIMED WATER SYSTEMSCROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS '' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION %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 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino t JAN 2 „ 2004 MAILING ADDRESS Tech Facifily Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773.6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975X1. RP 2° 1160281 INTERNAL ® TAG LOCATION OF DEVICE Chillerbldgl6 1st floor cooling tower Outside EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASK FAIL[:] • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHTa CLOSED TIGHT OPENED AT , LBS. OPENED AT_UBS CLOSED TIGHT ❑ INITIAL #Ibs. #lbs. #LBS #LBS, TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED Cl OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT_LBS 1 LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BVCERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. .•REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE 'N• MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSV BACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464,F,LQW(2S6� 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 R_I--F,c �'v'FD 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2850 s-J JAN 2 ® 2004 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773-6220 Buffalo Grove, U,60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Hersey FRPII RP 3/4" NA INTERNAL ® TAG LOCATION OF DEVICE boiler room bldg 16 Ist floor mechanical room EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASsx_FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHTO CLOSED TIGHT OPENED AT LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL 0Ibs. ], pubs. *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 ❑ CLOSED TIGHT 11TEST #LBS #LBS OPENED AT_LBS OPENED AT_LOS i LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO, 2656 DATE 12-10-03 MO_ DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE `� -MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION sA+asuats�9.b• %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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino/X-Pmneridge ! AN 2 0 2004 MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Dave Il�Wyl 801 Asbury Dr TEL# 773-6220 Buffalo Grove,M 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Hersey FRP-II RP 3/4" 143477 INTERNAL ® TAG LOCATION OF DEVICE basement Chiller Bldg 16 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS—FAIL❑ . REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE/RELIEF NO.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSED TIGHT OPENED ATZ ;—' LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #lbs. #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 ❑ OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST #LBS #LBS /LOS- THE ABOVE REPORT IS CERTIFIED TO BE TRUE - - -' INITIAL TEST BY CERTIFIED TESTER_NO.2656 DATE 12-10-03 i MO. DAY YR. • REPAIRED BY DATE , �i FINAL TEST BY CERTIFIED TESTER NO. DATE MO /,DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMSCROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS '' BACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION %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 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino t JAN 2 „ 2004 MAILING ADDRESS Tech Facifily Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773.6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975X1. RP 2° 1160281 INTERNAL ® TAG LOCATION OF DEVICE Chillerbldgl6 1st floor cooling tower Outside EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASK FAIL[:] • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHTa CLOSED TIGHT OPENED AT , LBS. OPENED AT_UBS CLOSED TIGHT ❑ INITIAL #Ibs. #lbs. #LBS #LBS, TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED Cl OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT_LBS 1 LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BVCERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. .•REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE 'N• MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSV BACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464,F,LQW(2S6� 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 R_I--F,c �'v'FD 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2850 s-J JAN 2 ® 2004 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773-6220 Buffalo Grove, U,60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Hersey FRPII RP 3/4" NA INTERNAL ® TAG LOCATION OF DEVICE boiler room bldg 16 Ist floor mechanical room EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASsx_FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHTO CLOSED TIGHT OPENED AT LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL 0Ibs. ], pubs. *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 ❑ CLOSED TIGHT 11TEST #LBS #LBS OPENED AT_LBS OPENED AT_LOS i LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO, 2656 DATE 12-10-03 MO_ DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE `� -MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION sA+asuats�9.b• %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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100 Tantau Ave.,Cupertino/X-Pmneridge ! AN 2 0 2004 MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Dave Il�Wyl 801 Asbury Dr TEL# 773-6220 Buffalo Grove,M 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Hersey FRP-II RP 3/4" 143477 INTERNAL ® TAG LOCATION OF DEVICE basement Chiller Bldg 16 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS—FAIL❑ . REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE/RELIEF NO.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSED TIGHT OPENED ATZ ;—' LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #lbs. #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 ❑ OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST #LBS #LBS /LOS- THE ABOVE REPORT IS CERTIFIED TO BE TRUE - - -' INITIAL TEST BY CERTIFIED TESTER_NO.2656 DATE 12-10-03 i MO. DAY YR. • REPAIRED BY DATE , �i FINAL TEST BY CERTIFIED TESTER NO. DATE MO /,DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS A>, �j INSTALLATION -CERTIFICATION • S �9s� "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)269.2800 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100& 10200 Tantau Ave.,Cupertino MAILING ADDRESS TTRmmel Crow CO CONTACT Gene 10555 Ridgeview Ct TEL# 623-0045 Cupertino,CA 95014 MANUFACTURER _ MODEL NUMBER TYPE SIZE SERIAL NUMBER Wiildns 975XL RP 2e 1482981 INTERNAL ❑ TAG LOCATION OF DEVICE irrigation Bldg 16 on Stevens Creek Blvd EXTERNAL ® - (replaces S4499) IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX(511 PASS WFAILO . .REDUCED PRESSURE - '- ' ,:. .,..� .,,.. �. •/ PRESSURE TYPE:"„. • DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF NO.1 NO.2 VALVE AIR INLET CHECK VALVE CLOS TIGHT CLOSED TIGHT OPENED AT.2L—LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #Ibe. / #Ibs. #LBS #LBS, TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT_LBS I LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE - ( 2 INITIAL TEST BY �. .. . .—. _ .__._. -_....._._..__.. 48 CERTIFIED TESTER NO. DATE 2-24-03 Md.* 'DAY YR. -. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS • BACKFLOW PREVENTION VALVE EXPERT ' � � INSTALLATION-REPAIRS-TESTING-CERTIFICATION Sfroa�llnti �«°' *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)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)265-2650 SERVICE ADDRESS 10100& 10200 Tantau Ave.,100& 10200 Tantau Ave. CuNrtino MAILING ADDRESS Trammell CLOW CONTACT GCne 10555 Ridgeview Ct TEL# 623-0045 Cupertino,CA 95014CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975XL RP -- 2° 1482982 INTERNAL TAG LOCATION OF DEVICE cooling tower back of bldg inside Cyclone fence EXTERNAL ❑ Bldg 4 (replaces 19688) IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX Ip PASS& FAIL❑ . REDUCED PRESSURE DEVICES / PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECKVALVE CLOSE❑RTIGHT CLOSED TIGHT OPENED AT zyLBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #lbs. O 0 Olbu #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED Cl 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 C3 TEST #LBS #LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE (�.. 2' INITIAL TEST BY CERTIFIED TESTER NO,48 DATE 2-24-03 MO. DAY YR. • REPAIRED BY 047E FINAL TEST BY CERTIFIED TESTER NO, DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS �_ •��//��.,yam,__ CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS LLQ, - �f INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC. `--""` ' u JF� LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW$ 9)• 3750-E CHARTER PARK DR.,SAN JOSE CA 95136.1356 (408)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 .JAN 2 0 2004 SERVICE ADDRESS 10100& 10200 Tantau Ave.,Cupertino Ew. MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773.6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825Y RP 2° S4499 INTERNAL ® TAG LOCATION OF DEVICE irrigation Bldg 16 on Stevens Creek Blvd EXTERNAL ❑ I IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX PASS❑ FAIL❑ • REDUCED PRESSURE DEVICES PRESSURETYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF NO.1 NO.2 VALVE AIR INLET CHECK VALVE j CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL 9lbs. #Ibs. #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 OPENED AT_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST ALBS NLBS f UIS THE ABOVE REPORT IS CERTIFIED TO BE TRUE j INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION %ACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3589) 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1358 (408)269-2600 . 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 � .. SERVICE ADDRESS 10100& 10200 Tantau Ave.,Cupertino MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT DaVC v 801 Asbury Dr TEL# 773-6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975XL RP 2° 1482982 INTERNAL �� TAG LOCATION OF DEVICE cooling tower back of bldg inside cyclone fence EXTERNAL ❑ Bldg (replaces 19688) IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX[] PASSM -FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSED TIGHT-- OPENED AT3_ULES. OPENEDAT_LBS CLOSED TIGHT Cl INITIAL #lbs. /. K-1 #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 ❑ OPENEDATT LBS OPENED AT_LBS CLOSED TIGHT Ll TEST #LBS #LBS 8LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO.2656 ,DATE 12-10-03 MO. DAY YR. • REPAIRED BY DOTE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR: CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT I N STA L LATI O N-REPAIRS-TES T I N G-C E R T I F I CATI O N 3 qse• %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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10100& 10200 Tantau Ave.,Cupertino JAN 2 0 2004 MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773-6220 �Y: Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Willrins 975XL RP 2° 1482981 INTERNAL ❑ TAG LOCATION OF DEVICE irrigation Bldg 16 on Stevens Creek Blvd EXTERNAL ® (replaces 54499) IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[:] PASS FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSED TIGHT.EfOPENED AT Z6 LBS. OPENED AT_LaS CLOSED TIGHT ❑ INITIAL #lbs. f,.:9 a lbs. #LBS #USE. 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 OPENED AT_LBS OPENED A7_LBS CLOSED TIGHT❑ TEST ALBS #LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY 4 ti - O CERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DOTE FINAL TEST BY CERTIFIED TESTER NO, DATE MO. DAY YR. r