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BACKFLOW REPORTSCERTIFICATION OF RE-CLAIMED WATER SYSTEMS _ yy""���_yy CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSINSTALLATION-REPAIRS-TESTING-CERTIFICATION INSTALLATION -REPAIRS -TES T I N G -C E RTI F I CATI O N . Sraet'Uots��"O BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 3608 FERNWOOD ST., SAN MATEO CA 94403 SERVICE ADDRESS 19333 VaReo MAILING ADDRESS Tech Facility Sicmens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODELNUMBER TYPE Waw 909 RP CALIFORNIA (800) 464 -FLOW (3561 (408) 269-2600 FAX (408) 269-2650 JAN 2 Q 2004 CONTACT DaVC TEL# 773(220 SIZE SERIAL NUMBER 3" 120909 INTERNAL ❑ TAG LOCATION OF DEVICE�����c& EXTERNAL ❑ c) I��y9 o I;t IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX [3 PASS❑ FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 .10 CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE / RELIEF VALVE AIR INLET CHECK VALVE NO.1 NO.2 CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #Ibs. #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 Cl CLOSED TIGHT ❑ CLOSED TIGHT ❑ TEST # LBS #LBS OPENED AT _ LBS OPENED AT _ LBS 11 # LBS • ' THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 .10 CERTIFIED TESTER NO. DATE MO. DAY YR. 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 • Slax.(�s 91a 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 (408) 269-2600 1(� ,,//--�. 3608 FERNWOOD ST., SAN MATEO CA 94403 FAX (408) 269- SQ�IC:.-�+...�� SERVICE ADDRESS Vallco Parkway & Stevens MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODELNUMBER TYPE Febco 825 RP INTERNAL ® TAG EXTERNAL ❑ J 3 vd/ AN 2 0P02 A! CONTACT L)Wf TEL# 773-6220 SIZE SERIAL NUMBER 3" 9509051346 LOCATION OF DEVICE behind fence end Of lot IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FAIL❑ IRt ABOVE REPORT 15 CERTIFIED TO BE TRUE INITIAL TEST BY �� CERTIFIED TESTER NO. 2656 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 12-10-03 MO. DAY YR. DATE MO. DAY YR. 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 CHECKVALVE- CLOSEDTIGHT 9lbs. 6- y CLOSED-nGHT� #lbs. OPENEDAT?-o LBS. OPENEDAT_LBS #LBS CLOSED TIGHT C1INITIAL #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 #LBS #LBS OPENEDAT_LBS OPENEDAT_LBS t LBS IRt ABOVE REPORT 15 CERTIFIED TO BE TRUE INITIAL TEST BY �� CERTIFIED TESTER NO. 2656 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 12-10-03 MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS(vii'i y CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSBACKFLOW PREVENTION VALVE EXPERT INSTALLATION•REPAIRS-TESTING-CERTIFICATION • ` BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 484 -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) 289-2650 • SERVICE ADDRESS 19333 Vallco19333 Vallco Parkway, CAC2 Cu�rtinoCAC2 Cu�rtino MAILING ADDRESS Trammell Crow CONTACT Gane 10555 Ridgeview Ct Cupertino, CA 95014CA 95014 MANUFACTURER MODELNUMBER TYPE Watts INTERNAL ❑ TAG EXTERNAL 909 10 TEL# 623-0045 SIZE SERIAL NUMBER 4" 201212 LOCATION OF DEVICE concrete enclosure at meter IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX [3 PASSa FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 48 .0 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 1-06-03 MO. DAY YR. DATE MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE N0.1 N0.2 C3INITIAL CLO TIGHT CLOSED TIGH OPENEDAT� LBS. OPENEDAT_LBS CLOSEDTIGHT Albs. �� #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 ❑ CLOSED TIGHT ❑ CLOSED TIGHT C1TEST OPENED AT OPENED AT #LBS #1.113 _LBS _LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 48 .0 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 1-06-03 MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS Y��`�'�°//� CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS_,, -f INSTALLATION -REPAIRS -TESTING -CERTIFICATION Ifni S qie. lMaGrLleOs `%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 • SERVICE ADDRESS MAILING ADDRESS Tech Facility Bldg attn: Accounts Payable attn: Accounts Payable 801801 Asb�Dr Buffalo Grove, IL 60089 MANUFACTURER MODELNUMBER TYPE Hersey INTERNAL ® TAG EXTERNAL ❑ 1210[al CONTACT Uavc TEL# 773-6220 SIZE 2" LOCATION OF DEVICE Cooling tower bldg 1 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FAIL❑ SERIAL NUMBER 157824 THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BYCERTIFIED TESTER N0.2656 GATE 12-10-03 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. i T REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSEDTIGHT�� ' 7 OPENEDAT� LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL albs. 7 #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 ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT _LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BYCERTIFIED TESTER N0.2656 GATE 12-10-03 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. i T 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 1522-A DAY AVE., SAN MATEO CA 94403 FAX (408) 269-2650 • SERVICE ADDRESS 19333 VaDco MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE Wilkins INTERNAL ,®? TAG EXTERNAL ❑ 975XL ug CONTACT L)a TEL# 7734 SIZE 2" LOCATION OF DEVICE cooling tower bldg 3, 2 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS FAIL❑ SERIAL NUMBER 1195505 IIIc AUVVC KtrUKI IDbtK I NICU IU tlt IKUC INITIAL TEST BY CERTIFIED TESTER N0.2656 DATE 12-10-03 • REPAIRED BY DATE MO. DAY YR. ee FINAL TEST BYCERTIFIED TESTER Nd�' DATE MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF NO.i N0.2 VALVE AIR INLET CHECK VALVE CLOSED TI HT CLOSED TIGHT OW—OPENED 7 AT LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL NIbs. 7 #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 ❑ CLOSED TIGHT ❑ TEST #LBS #LBS OPENEDAT_LBS OPENED AT LBS _ tLBS IIIc AUVVC KtrUKI IDbtK I NICU IU tlt IKUC INITIAL TEST BY CERTIFIED TESTER N0.2656 DATE 12-10-03 • REPAIRED BY DATE MO. DAY YR. ee FINAL TEST BYCERTIFIED TESTER Nd�' 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 *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 1522-A DAY AVE., SAN MATEO CA 94403 FAX (408) 269-2650 E SERVICE ADDRESS MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE Watts 709 DC INTERNAL ® TAG EXTERNAL ❑ CONTACT TEL# SIZE 1" LOCATION OF DEVICE cooling towerbldg 3, 2 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FAIL❑ SERIAL NUMBER 61544F THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO, 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. 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 INITIAL CLOSED TIGHT 0Ibs. � CLOSED TuIGHT # lbs. /I/ OPENED AT _ LBS. OPENED AT _ LBS #LBS CLOSED TIGHT ❑ # 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 #LBS #LBS OPENED AT _LBS OPENED AT _LBS #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 FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS _ yy""���_yy CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSINSTALLATION-REPAIRS-TESTING-CERTIFICATION INSTALLATION -REPAIRS -TES T I N G -C E RTI F I CATI O N . Sraet'Uots��"O BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.# 427328 3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 3608 FERNWOOD ST., SAN MATEO CA 94403 SERVICE ADDRESS 19333 VaReo MAILING ADDRESS Tech Facility Sicmens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODELNUMBER TYPE Waw 909 RP CALIFORNIA (800) 464 -FLOW (3561 (408) 269-2600 FAX (408) 269-2650 JAN 2 Q 2004 CONTACT DaVC TEL# 773(220 SIZE SERIAL NUMBER 3" 120909 INTERNAL ❑ TAG LOCATION OF DEVICE�����c& EXTERNAL ❑ c) I��y9 o I;t IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX [3 PASS❑ FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 .10 CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE / RELIEF VALVE AIR INLET CHECK VALVE NO.1 NO.2 CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL #Ibs. #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 Cl CLOSED TIGHT ❑ CLOSED TIGHT ❑ TEST # LBS #LBS OPENED AT _ LBS OPENED AT _ LBS 11 # LBS • ' THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 2656 DATE 12-10-03 .10 CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS(vii'i y CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTSBACKFLOW PREVENTION VALVE EXPERT INSTALLATION•REPAIRS-TESTING-CERTIFICATION • ` BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 484 -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) 289-2650 • SERVICE ADDRESS 19333 Vallco19333 Vallco Parkway, CAC2 Cu�rtinoCAC2 Cu�rtino MAILING ADDRESS Trammell Crow CONTACT Gane 10555 Ridgeview Ct Cupertino, CA 95014CA 95014 MANUFACTURER MODELNUMBER TYPE Watts INTERNAL ❑ TAG EXTERNAL 909 10 TEL# 623-0045 SIZE SERIAL NUMBER 4" 201212 LOCATION OF DEVICE concrete enclosure at meter IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX [3 PASSa FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 48 .0 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 1-06-03 MO. DAY YR. DATE MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE N0.1 N0.2 C3INITIAL CLO TIGHT CLOSED TIGH OPENEDAT� LBS. OPENEDAT_LBS CLOSEDTIGHT Albs. �� #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 ❑ CLOSED TIGHT ❑ CLOSED TIGHT C1TEST OPENED AT OPENED AT #LBS #1.113 _LBS _LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 48 .0 REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE 1-06-03 MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS Y��`�'�°//� CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS_,, -f INSTALLATION -REPAIRS -TESTING -CERTIFICATION Ifni S qie. lMaGrLleOs `%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 • SERVICE ADDRESS MAILING ADDRESS Tech Facility Bldg attn: Accounts Payable attn: Accounts Payable 801801 Asb�Dr Buffalo Grove, IL 60089 MANUFACTURER MODELNUMBER TYPE Hersey INTERNAL ® TAG EXTERNAL ❑ 1210[al CONTACT Uavc TEL# 773-6220 SIZE 2" LOCATION OF DEVICE Cooling tower bldg 1 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FAIL❑ SERIAL NUMBER 157824 THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BYCERTIFIED TESTER N0.2656 GATE 12-10-03 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. i T REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT CLOSEDTIGHT�� ' 7 OPENEDAT� LBS. OPENEDAT_LBS CLOSEDTIGHT ❑ INITIAL albs. 7 #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 ❑ CLOSED TIGHT❑ TEST #LBS #LBS OPENED AT_LBS OPENED AT _LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BYCERTIFIED TESTER N0.2656 GATE 12-10-03 • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. i T 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 1522-A DAY AVE., SAN MATEO CA 94403 FAX (408) 269-2650 • SERVICE ADDRESS 19333 VaDco MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE Wilkins INTERNAL ,®? TAG EXTERNAL ❑ 975XL ug CONTACT L)a TEL# 7734 SIZE 2" LOCATION OF DEVICE cooling tower bldg 3, 2 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS FAIL❑ SERIAL NUMBER 1195505 IIIc AUVVC KtrUKI IDbtK I NICU IU tlt IKUC INITIAL TEST BY CERTIFIED TESTER N0.2656 DATE 12-10-03 • REPAIRED BY DATE MO. DAY YR. ee FINAL TEST BYCERTIFIED TESTER Nd�' DATE MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF NO.i N0.2 VALVE AIR INLET CHECK VALVE CLOSED TI HT CLOSED TIGHT OW—OPENED 7 AT LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL NIbs. 7 #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 ❑ CLOSED TIGHT ❑ TEST #LBS #LBS OPENEDAT_LBS OPENED AT LBS _ tLBS IIIc AUVVC KtrUKI IDbtK I NICU IU tlt IKUC INITIAL TEST BY CERTIFIED TESTER N0.2656 DATE 12-10-03 • REPAIRED BY DATE MO. DAY YR. ee FINAL TEST BYCERTIFIED TESTER Nd�' 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 *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 1522-A DAY AVE., SAN MATEO CA 94403 FAX (408) 269-2650 E SERVICE ADDRESS MAILING ADDRESS Tech Facility Siemens Bldg attn: Accounts Payable 801 Asbury Dr Buffalo Grove, IL 60089 MANUFACTURER MODEL NUMBER TYPE Watts 709 DC INTERNAL ® TAG EXTERNAL ❑ CONTACT TEL# SIZE 1" LOCATION OF DEVICE cooling towerbldg 3, 2 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FAIL❑ SERIAL NUMBER 61544F THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO, 2656 DATE 12-10-03 MO. DAY YR. • REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR. 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 INITIAL CLOSED TIGHT 0Ibs. � CLOSED TuIGHT # lbs. /I/ OPENED AT _ LBS. OPENED AT _ LBS #LBS CLOSED TIGHT ❑ # 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 #LBS #LBS OPENED AT _LBS OPENED AT _LBS #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 FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO. DAY YR.