NO PERMIT NUMBER (2) CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION-REPAIRS-TESTINGGCERTIFICATION
ILS
ACK 9 PREVENTION SPECIALISTS; INC.
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FL
3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 V L
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 lQ 9 9
Amp
SERVICE ADDRESS 1'9999�Ni•Blaney;Cupertino-/x-Stevens.Creek Blvd.
MAILING ADDRESS Travigne Villas CONTACT Jeff
1475 Saratoga Ave., Ste.250 TEL#
San Jose,CA 95129
MANUFACTURER MODELNUMBER TYPE SIZE SERIAL NUMBER
Febco 825Y RP2° A222610
INTERNAL Cl TAG LOCATION OF DEVICE mtr#62011048
EXTERNAL
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
CHECKVALVE CHECK VALVE PRESSURE/RELIEF
N0.1 N0.2
VALVE AIR INLET CHECKVALVE
CLOSED TIGHT CLOSED TIGHT OPENEDATCP'( LBS. OPENEDAT_LBS CLOSEDTIGHT ❑
.INITIAL #Ibs. to #lbs. #LBS #LBS.
TEST - OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKED Cl LEAKED ❑ OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED Cl
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT ❑ .CLOSED TIGHT ❑ OPENED AT LBSOPENED AT_LBS CLOSED TIGHT ❑
TEST #LBS #LBS #LBS'
THE ABOVE REPORT IS CERTIFIED TO BE TRUE -
INITIAL TEST BY ! 1 CERTIFIED TESTER NO. 10466 DATE 1-17-06
MO. DAY YR.
•REPAIRED BY DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE _
MO. DAY YR"