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BACKFLOW CROSS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS4,, BACKFLOWPREVENTIONCONNECTION SPECIALISTS EVALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS �.�j �I INSTALLATION-REPAIRS-TESTING-CERTIFICATION Slwvdaey 9p. %ACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.4 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 SERVICE ADDRESS 19191 Vallco Pkwy.,Cupertino MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury Dr T E L4 773-6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins 975XL RP 3/4" 1190649 INTERNAL ® TAG LOCATION OF DEVICE boilerbldg4 lstfloor EXTERNAL ❑ 11 JAN 2 0 2004 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASSI!�—F • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE UU CLOSED TIGHT- CLOSEDTIGHTT— OPENEDAT/Z LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #lbs. A�; #Ibs. #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❑ CLOSED TIGHT ❑ OPENED A7_LBS OPENED AT_LBS CLOSED TIGHT❑ TEST #LBS #LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY Z CERTIFIED TESTER No, 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DOTE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ��- ��-���///,��.rrr CROSS CONNECTION SPECIALISTS , CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS _,, BACKFLOW PREVENTION VALVE EXPERT,l,p INSTALLATION-REPAIRS-TESTING-CERTIFICATION %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 410.3 FAX(408)269-(408)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 92656AN SERVICE ADDRESS Vallco Parkway&Stevens Creek,Cupertino / 9 �J/ 2 2004 MAILING ADDRESS Tech Facility Bldg attn:Accounts Payable attn:Accounts Payable CONTACT DavO'By 801 Asbury Dr TEL# 773-6220 Buffalo Grove,IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 805 .1w R_'� 4" 6232 INTERNAL ❑ TAG LOCATION OF DEVICE 2nd vault right of driveway irrigation 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 CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED�TjIGH - CLOSED TIGH OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #lbs. A / #Ibs. /Z #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 Cl CLOSED TIGHT❑ TEST #LBS #LBS OPENEDAT_LBS OPENED AT_LBS #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 DOTE FINAL TEST BY CERTIFIED TESTER NO. DATE MO."QDAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS 'P/�"-° :"fie CROSS CO NPREVENTIONTION SPECIALISTS EVALVIS EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ._,,�� INSTALLATION-REPAIRS-TESTING-CERTIFICATION S �/�w[tay q�e.. BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800) F1'7W(3569.j �� 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 IAI SERVICE ADDRESS 19191 VaIICo Pkwy.,Cupertino/X-Pnmeridge MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave 801 Asbury DT TEL# 773-6220 Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 805 DC 2° 19688 INTERNAL ® TAG LOCATION OF DEVICE bldg 4 EXTERNAL ❑ ��n�g,c Cii�i , y Q IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS❑ FAIL❑ •. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF NO.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #lbs. #lbs. ALBS #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❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST ALBS #LBS OPENED AT_LBS OPENED AT_LBS 1 LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO, DATE MO. DAY YR. 6