BACKFLOW CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS .a'� BACKFLOW PREVENTION VALVE EXPERT
�f INSTALLATION-REPAIRS-TESTING-CERTIFICATION
�,, 'Sha�[tus�9s4• 'i
BACKFLOW PREVENTION SPECIALIS �� t Na D
LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW(3589)
3750-E CHARTER PARK DR.,SAN JOSE CA 95138.1358 (408)269-2600
3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650
SERVICE ADDRESS 19000 Homestead Rd.,Cupertino/X-Tantau
MAILING ADDRESS Kaiser Hospital Santa Clara Attn:Ron Cappa CONTACT ROn Cappa
900 Kiely Blvd. TEL# 2641057
Santa Clara,CA 95050
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
conbraco 40208x2 RP 2" 55334632
INTERNAL ❑ TAG LOCATION OF DEVICE
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PAS Syq i�FAIL❑
• REDUCED PRESSURE DEVICES
SA
PRESSURE TYPE
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECKVALVE CHECK VALVE PRESSURE/RELIEF
NO.1 N0.2
VALVE AIR INLET CHECKVALVE
��11
CLOSED TIGHT I CLOSED TIGHT OPENED AT WBS. OPENED AT_LES CLOSED TIGHT ❑
INITIAL #16e. #lbs. .. #LBS #LBS,
TEST OPENED UNDER 2.0 OPENED UNDER 1.0
LEAKED Cl LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ OPENEDAT_LBS OPENED AT_LBS CLOSED TIGHT❑
TEST #LBS #LBs 9HIS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY \ � �Q CERTIFIED TESTER NO. 7 D j J DATE
MO. DAY YR.
• REPAIRED BY
DATE
FINAL TEST BY CERTIFIED TESTER NO, DATE
MO. DAY YR.