BACKFLOW TEST CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS,
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION-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 (40B)269-2600Tf'1
1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 p r CR�VED
Vallco Parkway //
SERVICE ADDRESS y&Stevens Creek,Cupertino pzoo q/, U-n//air/ JAN 2 0 2004
MAILING ADDRESS Tech Facility Bldg attn: Accounts Payable attn: Accounts Payable CONTACT Dave BY' --
801 Asbury Dr TEL# 773-6220
Buffalo Grove,IL 60089
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts 909 RP 4" 166966
INTERNAL ❑ TAG LOCATION OF DEVICE FJS Tantau 75'N of Vallco Parkway
EXTERNAL ® meterprotection BldgCAC15
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/RELIEF
N0.1 N0.2
VALVE AIR INLET CHECK VALVE
CLOSED TIGHT CLOSED TIGHT OPENEDATZ•O LBS. OPENEDAT_LBS CLOSED TIGHT ❑
INITIAL #lbs. 6 #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 OPENEDAT_LBS OPENED AT_LBS
t LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY —CERTIFIED TESTER N0. 2656 DATE 12-10-03
MO. DAY YR.
• REPAIRED BY DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.