NO PERMIT NUMBER (4)•
F, 1
BACKFLOW CERTIFICATION
SERVICE ADDRESS: 1 q 083 5 rantyU0. � N �(.(.
DEVICE LOCATED:
RETURN TO: ACCT NO
Cal -Air, Inc.
1555 South Seventh St.
San Jose, CA 95112
Ph. (408) 283.2300
Pax. (408) 293.9511
METER NO.
L..131115
Mailin Address
rtr?i�%�P?>t�?"i?':',DEVICE,INFORMATION�7k�a,r�i..i;-t�Tsl»:'s
Type W Size - MFG
Model S(96 SER. NO NO Z3Q
TYPE OF SERVICE
❑ DOMESTIC 1�r IRRIGATION
❑ INDUSTRIAL ❑ FIRE
CONTACT:
.lab Number REPORT OF TEST RESULTS PASS ❑ FAIL
REDUCED REDUCED ASSEMBLY
DOUBLE CHECK
I`N(�PRESS_UR6VACUUM�6REAKERait'
Air Inlet Check Valve
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MODULE 1:1
OTHER ❑OTHER
CLEANED LJ
REPLACED ❑
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SEAT ❑
MODULE ❑
❑MODULE,Type
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REPLACED ❑
DISC(S) ❑
SPRING
DIAPHRAGM(S) ❑
SEAT(S) ❑
O -RINGS ❑
OTHER
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Note: Please keep in your files for 3 years
)(ob5
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
REPAIRED BY: DATE:
FINAL TEST BY:Sp(D4f 801 5 /r CERTIFIED TESTER NO. DATE:
COMMENTS: J7 r - g 7ron�" a(d� f r rl gC.4nD A'
Fostar City Glendale I.as Angeles Socramento Son Francisco Santa Rosa
Fresno Livermore Orange San Dief!o San Jose Salinas Whittier Ontario