NO PERMIT NUMBER (7) Cal-Air, Inc.
w 1555 South Seventh St.
Son Jose, CA 95112
)S Ph. ' (408) 283.2300
Fax. (408) 293.9511
- LNItIll95
BACKFLOW CERTIFICATION
SERVICEADDRESS: 10Y3S TA11+4u r GuPC14ln9 BL2�
DEVICE LOCATED: aldg Q,G
RETURN TO: ACCT NO. METER NO.
Mailing Address '
,.....,- ... ,lu
'�'�'��." 'rw",�+'IDEVICEINFORMATION�e�,:
Type Size Zft MFG W 4}
Madel V0O9 P"2QT SER.NO AILIJ
TYPE OF SERVICE
❑ DOMESTIC ❑ IRRIGATION
CONTACT: ® INDUSTRIAL ❑ FIRE
Job Number REPORT OF TEST RESULTS 4 PASS ❑ FAIL
REDUCED REDUCED ASSEMBLY !I.LPRESSURE.VACUUM BREAKER:%�
DOUBLE CHECK Air Inlet Check Valve
LCHEOK VALV,Ei a'r111. 6HECKVALVE r,'F��,' 'f�n'�¢�`RELIEFj .?{",`a45:�r#'Sl Opened at Closed Tight
rNO2�zi 'i t!ln�lt fir- 1VALVEtk��61111t (��IK" PSID
�' ry41 `t`fi1Nrj�;1 CLOSED TIGHT CLOSED TIGHT LE OPENED AT r rJ PSID PSID
N�ITIALtyi� LEAKED ❑ LEAKED ❑ Opened Under 1.0 PSID
p TEST 11 ❑
Did Not Open Leaked
(44�r PSID t S ❑ CLOSED TIGHT ® UNDER 2.0 PSI ❑ h�h''l��jN(n'ntSHUT=OF.F VALVE utaaz��"441
Y,00P LEAKED ❑ LEAKED ❑ DID NOT OPEN N0.1 N0.2
e
d' }4'^1jI CLEANED CLEANED CLEANED ❑ ❑ LEAKED ❑
r ❑ - CLOSED TIGHT ❑
1
°❑ ❑
�ri�R REPLACED ❑ REPLACED ❑ REPLACED
4: „� ,ts DISC ❑ DISC ❑ DISC(S) ❑ CLEANED
''� 'lt SPRING ❑ SPRING' ❑ SPRING ❑
ff:°"REPAIRS; ., ❑ GUIDE ❑ ❑
❑ DIAPHRAGMS) ❑ REPLACED
GUIDE
c , SEAT ❑ SEAT ' ❑ SEAT(S) ❑
,3v'r,A— MODULE ❑ MODULE ❑ O•RINGS ❑ Replaced With
OTHER ❑ OTHER ❑
MODULE
IE�t` n1,fK OTHER Type
CLOOLSEq�,TIGHT CLOSED TIGHT OPENED_AT
1�:1`kYiTES7Ss !iy— PSID q•S PSID Z..,) PSID
Mf
Note:Please keep in your files for 3 years.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
REPAIRED BY: DATE:
FINAL TEST BY: SCOTT L;GGLH3 CERTIFIED TESTER NO. {0662- DATE: 03-11-04
COMMENTS: Afq•5
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Fostar City Glendale Los Angalas Sacramento San Francisco Santa Rosa
Fresno Lvennare Ciange Gan Di(610 San JDSo 33llnas Whittier Cnlado