BACKFLOWCERTIFICATION OF RE-CLAIMED WATER SYSTEMS �????�//�� CROSS CONNECTION SPECIALISTS
BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS a'�
V INSTALLATION -REPAIRS -TESTING -CERTIFICATION
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%ACKFLOW PREVENTION SPECIALISTS, INC,
LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 484-FLOVJQ 8
3750-E CHARTER PARK DR., SAN JOSE CA 95138-1356 F �� 2��Iff'-�?�-W�-(^:�TZTED
1522-A DAY AVE.. SAN MATEO CA 94403
SERVICE ADDRESS
MAILING ADDRESS Shri Chawla
10377 Avenida Ln
Cupertino, CA 95014-3946
MANUFACTURER MODEL NUMBER TYPE
Watts 909-M1
INTERNAL ❑ TAG
EXTERNAL
m
CONTACT Shn
TEL# 996-8858
SIZE SERIAL NUMBER
1 1/4" 336171
LOCATION OF DEVICE prop# 41-055-6701-1 acct# 295095 work zone Z
20461694
•,;IF DEVICE ISA NEW INSTALLATION PLEASE CHECK THIS BOX [3 PASSIM FAIL❑
L
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY•/-' _..__!...___ CERTIFIED TESTER N0. 9815 DATE -4=19-04
_ /y MO DAY YR
l
REPAIRED BY a,� „ DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.
REDUCED PRESSURE DEVICES
-' -
.. .. ....... .._ ..._ ...._...--- --- ... .. ..... __._. .....
...,., ._. .... PRESSURETYPE. ... .____ .. .
` -`)'
VACUUM BREAKERS:-`)'
DOUBLE CHECK VALVES
RPP VALVES
DIFFERENTIAL
CHECK VALVE
CHECK VALVE
PRESSURE I RELIEF
VALVE
AIR INLET
CHECK VALVE
NO.1
NO.2
-
CLOSED TIGHT ❑
CLOSED TIGHT ❑
OPENEDAT_LBS.
OPENEDAT_LBS
CLOSED TIGHT ❑
INITIAL
#lbs.
#lbs.
#LBS
II LBS.
TEST
-
OPENED UNDER 2.0
OPENED UNDER 1.0
LEAKED ❑
LEAKED ❑
OR DID NOT OPEN ❑
OR DID NOT OPEN ❑
LEAKED ❑
V( �lI e-�
REPAIRS
AND
' p5
C
Q IV F F0 f-) 5
MATERIALS
-
F
USED
FINAL
CLOSJD/TIGHT
CLOSED TIGHT
OPENED AT �BS
CLOSED TIGHT❑
TEST
#LBS W
#LBS
OPENEDAT_LBS
#LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY•/-' _..__!...___ CERTIFIED TESTER N0. 9815 DATE -4=19-04
_ /y MO DAY YR
l
REPAIRED BY a,� „ DATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.