Backflow Prevention Specialists CERTIFICATION OF RE-CLAIMED WATER SYSTEMS S"-• CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
�f INSTALLATION-REPAIRS-TESTING-CERTIFICATION
Siaeecalpr��w6'
%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
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269.2650
SERVICE ADDRESS 10104 Vista Dr.,Cupertino/X-Stevens Creek Blvd
MAILING ADDRESS.Cupertino Community Service CONTACT Gary
10104 Vista Dr TEL# 255-8033
Cupertino,CA 95014
MANUFACTURER MODEL NUMBER _ ITYPE _ SIZE SERIAL NUMBER
Febco 860 RP 4" _01.1030I 39�D
INTERNAL ❑ TAG LOCATION OF DEVICE behind the fire station I L
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS pR FAIL❑
• REDUCED PRESSURE DEVICES -
I,.• 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 TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSED TIGHT. ❑
INITIAL 1'Iba. D 0u. OLBS 0 LBS.
TEST OPENED UNDER 2.0 OPENED UNDER 1.0
gg LEAKED,A / LEAKED ❑ OR/DID NOT�OPPEN OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS G�''�I�iGG6 G/�P1vY
AND Clr.GI� Sa-/•7�'C'P
MATERIALS
USED ✓�sC
FINAL CLOSW TIGHT CLOSED TIGHT $- O CLOSED TIGHT❑
TEST OPENED AT_LBS 'OPENED AT_LBS
/LBS �� OLBS /LBS
THE ABOVE REPORT 19 CERTIFIED TO SE TRUE
INITIAL TEST BY CERTIFIED TESTER NO.2656 DATE 2-04-05
,! MO. DAY YR.
• REPAIRED BY �✓� DATE '� -�`Y ✓�
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.