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BACKFLOW REPORT 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(3569) 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 3606 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 _ 1 SERVICE ADDRESS 10501 N Tantau Ave.,Cuperfino JAN 9 0 { MAILING ADDRESS Tech Facility Siemens Bldg alts: Accounts Payable CONTACT Dave 801 Asbury Dr TEL# 773.6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Willdns 575 RP 21/2" W39661 INTERNAL ❑ TAG LOCATION OF DEVICE irrigation main Bldg 8 in front EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASSjr'FAIL❑ • REDUCED PRESSURE DEVICES 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 CLOSED TIGHT CLOSED TIGHT— OPENED ATL--2-LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #lbs. 1� #lbs. #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED Cl OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT #LBS #LBS ❑ TEST OPENEOATy_LBS OPENEDAT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE A/J 1 INITIAL TEST BVSAT-ry�== ERTIFIED TESTER N0. 2656 . ,DATE 12-10.03 MO. DAY YR. a , • 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 S��gwe. %ACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800) .LQVY:(3589)IVFD 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 0�� �'!' 1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 10501 Tantau Ave.,Cupertino MAILING ADDRESS Tech Facility Sicmens Bldg attn: Accounts Payable CONTACT Davc 801 Asbury Dr TEL# 773-6220 Buffalo Gmve,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Watts 909 RP 2" 146216 INTERNAL ® TAG LOCATION OF DEVICE boilermom Bldg 8 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 CHECK VALVE PRESSURE I RELIEF NO.1 NO.2 VALVE AIR INLET CHECK VALVE CLOSEED�,TIGHT CLOSED TIGHT OPENED ATZ �- LBS. OPENEDAT_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 Cl CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST #LBS ALBS OPENEDAT_LBS OPENED AT_LBS #L#s THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BYC ERTIFIED TESTER NO.2656 DATE 12-10-03 MO. DAY YR. REPAIRED BY • DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY VR.