NO PERMIT NUMBER (6) CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ,
INSTALLATION-REPAIRS-TESTING-CERTIFICATION
• S�+aLsllW��p
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)269-2600T�
1522-A DAY AVE., SAN MATEO CA 94403 FAX(408)269-2650 �i��'��'FINED
JAN 2 6 2004
SERVICE ADDRESS 10435 N Tantau Ave.,Cupertino
MAILING ADDRESS Tech Facility Siemens Bldg attn:Accounts Payable CONTACT Dave BY'
801 Asbury Dr TEL# 746-5584
Bu11•alo Grove,IL 60089
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Febco 825 RP 2 1/2" C9050
INTERNAL ❑ TAG LOCATION OF DEVICE mainwaterbldg7
EXTERNAL ® weekend
IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS-BOX❑ PASS$ FAIL❑
• REDUCED PRESSURE DEVICES
PRESSURE TYPE - . .-
DOUBLECHECKVALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECKVALVECHECK VALVE PRESSURE/RELIEF
N0.1 N0.2
VALVE AIR INLET CHECK VALVE
�A
CLOSED TIGHT CLOSED TIGHT M OPENEDAT _ _BS. OPENEDAT_LBS CLOSEDTIGHT ❑
INITIAL #16"._ y�; ,'.._ #Ibs. TTT #LBS #LB$,
TEST OPENED UNDER 20 OPENED UNDER 1.0
'. LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS kepaort
s
/� C D (�
AND we jo/sc C,y�a 401 C�. /' J� 7lCY�J
MATERIALS VA
USED
FINAL CLOS)vD'LIGHT❑ CLOSED TIGHT ❑ CLOSED TIGHT❑
TEST #LBS 6 #LBS OPENEDAT R�& OPENED AT_LBS
t LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
_...._
INITIALTEST BY / �'i '%/' CERTIFIED TESTER NO 9815 DATE• 1-17-04
.� -, • .__. - _...__. ._..._ MO. DAY YR.
.REPAIRED BY DATE
/// - ., .. I" I'• r" I-'
FINAL TEST BY / �� CERTIFIED TESTER NO. DATE
I - MO. DAY YR.