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BACKFLOW REPORT CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS a' INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISIl CINQ-tri- LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464E OW J3HSI6V)2 © 2��4 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICEADDRESS Vallco Parkway&Stevens Creek,Cupertino iyjov�/yzoo n , Ta_ � 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 Watts 909 RP 4" 163453 INTERNAL ❑ TAG LOCATION OF DEVICE Stevens Creek Bldg 15-16 near PIV EXTERNAL ® Bldg CAC-16 meter protection 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 CHECK VALVE PRESSURE I RELIEF NO.i N0.2 VALVE AIR INLET CHECK VALVE J— CLOSED TIGHT CLOSED TIGHT .Nf OPENED AT LBS. OPENED AT_UBS CLOSED TIGHT �p ❑ INITIAL 0lbs. .o IbS. #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS c AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ OPENED AT LBS OPENED AT_LBS CLOSED TIGHT TEST ALBS #LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY J` '�:%�A/�G�. CERTIFIED TESTER No.2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR.