BACKFLOW CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
I NSTALLATION-REPAIRS-TESTING-CERTIFICATION
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%ACKFLOW PREVENTION SPECIALISTS, INC.
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)4&i-FLOW(3589)
3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-26.
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SERVICE ADDRESS Comer of De Anna 8t Stevens Creek,Cupertino NU V 4 _H'3
MAILING ADDRESS Robert A Bothman CONTACT G'e LJ
650 Quinn Ave TEL# 639-1313
San Jose,CA 95112
.- MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Willdns 975XIL RP 3/4" 926686
INTERNAL ❑ TAG LOCATION OF DEVICE mtr#62024871
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
NO.1 NO.2 VALVEE AIR INLET CHECK VALVE
CLOSEL DT. IyHT CLOSED TIGHT OPENED AT f•VLBS. OPENEOAT_LBS CLOSEDTIGHT ❑
INITIAL #lbs.. (/J 0Ib& #LBS 0LBS.
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 AT_LBS OPENED AT CLOSED TIGHT❑
TEST #LBS #LBS _LBS_ $LBS
THE ABOVE REPORT IS CERTIFIED TO BBEE/TRUE
INITIALTESTBV C/• — - CERTIFIED TESTER NO. 9815 DATE 11-19-03
MO. DAY YR.
• REPAIRED BY _
CATS
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
�j 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 (408)269'2800
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(469)269.2650
SERVICE ADDRESS Comer of De Anja&Stevens Creek Ann&Stevens Cue rtino
MAILING ADDRESS Robert A Bothman CONTACT George
650 Quinn Ave TEL# 639-1313
San Jose,CA 95112
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Febco 825Y RP 2° AL5570
INTERNAL ❑ TAG LOCATION OF DEVICE mtr#62024871
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASSXFAIL❑
• 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
111,,,���
CLOSED TIGHT CLOSED TIGHT ly OPENED AT�LBS. OPENED AT_LBS CLOSED TIGHT ❑
INITIAL #Ib#. � #Ibe. , ` #LBS #LBS.
TEST OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKED ❑ LEAKED ❑ OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT Cl CLOSED TIGHT Cl CLOSED TIGHT❑
TEST #LBS #LBS OPENED AT_LBS OPENED AT_LBS
t LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
e
INITIAL TEST BY CERTIFIED TESTER NO. 9815 DATE 11-19-03
MO. DAY YR.
•REPAIRED BY
DATE
FINAL TEST BY CERTIFIED TESTER NO, DATE
MO. DAY YR.