BACKFLOW Cal-Air, Inc.
1555 South Seventh St.
C L-AIRF
Son Jose, CA 95112
Ph. (408) 283.2300
Pax. (408) 293.9511
Lk Yt]i]86
BACKFLOW CERTIFICATION
SERVICE ADDRESS: /0 q00 -ree4at-t CLt pee h;, ,A-pp4 SLoLl
DEVICE LOCATED: I,*AITUrt
RETURN TO: ACCT NO. METER NO.
Mallin Address 1?d;r#i? rsi±+lai�t i+ DEVICEINFORMATIONIr:ir"' Fi.°�r�,tv :i
Type PVC Size 2r MFG W475
Model _$06m61CIT SER.NO 02D593
TYPE OFSERVICE
❑ DOMESTIC L] IRRIGATION
CONTACT: ❑ INDUSTRIAL ❑ FIRE
,lob Number REPORT OF TEST RESULTS ❑ PASS ❑ FAIL
4 Vi1
REDUCED REDUCED ASSEMBLY ( ;"PRE56UREVA000 M BREAKER4:�t'
a� �DOppUBLE CHECK Air Inlet Check Valve
'
'&'20 't CHECKiVALVEIIIe 'CFIECK�,VALVE '1�� �'j`jlj�rglt RELIEF I�iYx +ij� Opened at Closed Tight
/if+.rri P1 Y )l9If. "rn.�.rmN0.1 ?I�i „tN0.21 "9 s+nN t]i{ �`�rIVALVEr �_.,8t PSID 1-8
CLOSED TIGHTLj CLOSED TIGHT OPENED AT PSID PSID
$$}}����*"INITUIL,7",h
7 ' LEAKED
r4r i ❑ LEAKED ❑ - 8 Opened Under 1 0 PSID
sTEST ❑ Leaked
a ] q Itp kir Did NotO n
itvu 4�a PSID ❑ CLOSED TIGHT ❑ UNDER 2.0 PSI ❑ {I ��iilW SHUt-0Ffl.VALVErai
C�P; LEAKED ❑ LEAKED ❑ DID NOT OPEN NOA NO.2
�$u CLEANED CLEANED CLEANED ❑' ❑ LEAKED 0
If t� CLOSED TIGHT LL5
$ ' Ir `1oi16ls i REPLACED ❑ REPLACED ❑ REPLACED ❑
Mill ry h,. DISC
�'t�'' ��" ❑ DISC ❑ D160(S) ❑ ❑ CLEANED ❑
+� a' SPRING ❑ SPRING ❑ SPRING
I;, gip " ....... GUIDE ❑ GUIDE ❑ DIAPHRAGM(S) ❑ ❑ REPLACED ❑
SEAT ElSEAT ❑ SEAT(S) ❑�',`i -" � I
MODULE MODULE ElO•RINGS ❑ Replaced With
t ' OTHER OTHER MODULE _
❑
'�.N21,R�A ainl3trGa OTHER Type
`9�7FIIAIi'tI CLOSED TIGHT CLOSED TIGHT OPENEDAT
3
r3ri11v'gai^-ir"1 a'ry
<7°:wrw(:TEST.L(n�ts' PSID PSID 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: stn{t ey I Ilf ((`` CERTIFIED TESTER NO. Ob S L DATE: s-o-01
-01
COMMENTS: — FYD/1'F c; 131JI . IrriLva H9
•
Foster Clty Glendale Los Angeles Sacramento San Francisco Santa Rosa
Fresno Livenncne Orange San Diep,v San use Salinas Whittiei Ontario
CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS _,' BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION-REPAIRS-TESTING-CERTIFICATION
S}amr�e�9ae. ..
%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)269'2600
1522-A DAY AVE.,SAN MATEO CA 94403 FAX(408)269-28 F, P"C' '9 u v.���
�oyo� JAN 2 0 2004
SERVICE ADDRESS +9369N Tantau Ave.,ClIperfino
MAILING ADDRESS Tecb Facility Siemens Bldg attn: Accounts Payable CONTACT Dav T-y.
801 Asbury Dr TEL# 773-6220
Buffalo Grove,IL 60089
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
SNM 720 PVB 2° P504964
INTERNAL ® TAG LOCATION OF DEVICE bldg 14
EXTERNAL Cl
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX E3 PASS FAIL❑
• REDUCED PRESSURE DEVICES PRESSURE TYPE
DOUBLE CHECK VALVES VACUUM BREAKERS
RPP VALVES DIFFERENTIAL
CHECKVALVE CHECK VALVE PRESSURE I RELIEF
N0.1 N0.2
VALVE AIR INLET CHECK VALVE
CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENEDAT_LBS. OPENEDATZ LBS CLOSEDTIGHT �—
INITIAL 9lbs. #lbs. ALBS #LBS.
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 LES CLOSED TIGHT
TEST #LBS ALBS #LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST BY CERTIFIED TESTER NO, 2656 DATE 12-10-03
MO. DAY YR.
• REPAIRED BY
DOTE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.
1�