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NO PERMIT NUMBER CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION S�ae�p�9se• %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 1\_ e rim7F SERVICE ADDRESS 10435 N Tantau Ave.,Cupertino JAN 2 0 2004 MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable CONTACT Dave BY: 801 Asbury Dr TEL# 773-6220 Buffalo Grove, U,60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825Y RP 2° P2244 INTERNAL ® TAG LOCATION OF DEVICE mechpadbldg7 EXTERNAL ❑ IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PAS50-FAIL❑ ,• REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECKVALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSED TIGHT OPENEDAT?-•C� LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #lb.. lbs. #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 ❑ OPENED AT_LBS OPENED A7_LBS CLOSED TIGHT❑ TEST #LBS #LBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. \Y• 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 CONSULTANTSBACKFLOW PREVENTION VALVE EXPERT INSTALLATION-REPAIRS-TESTING-CERTIFICATION • Shalvu�?� BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3569) 3750-E CHARTER PARK OR.,SAN JOSE CA 95136.1356 (408)269-2600 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 JAN 2 . 2004 SERVICE ADDRESS 10435 N Tamau Ave.,Cupertino Tech Facility Siemens Bldg attn: Accounts Payable Dave BY- MAILING ADDRESS tY g Y CONTACT 801 Asbury Dr TEL# 773-6220 Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825 RP 21/2" C9050 INTERNAL ❑ TAG LOCATION OF DEVICE main waterbldg 7 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS❑ FAIL2( lo REDUCED PRESSURE DEVICES s^s 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 ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL #lbs. #lbs. #LBS #LBS, TEST /' OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ORDIDNOTOPENX OR DID NOT OPEN ❑ LEAKED Cl REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT_LBS 0LBS THE ABOVE REPORT IS CERTIFIED TOBETRUE INITIAL TEST BY .frits// CERTIFIED TESTER N0.2656 DATE 12-10-03 MO. DAY YR. REPAIRED BY DOTE � N5 FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR.