BACKFLOW PREVENTION CERTIFICATION OF RE-CLAIMED WATER SYSTEMSt CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'F' Y" BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION-REPAIRS-TESTING-CERTIFICATION
CALIFORNIA (800)464-FLOW(3569)
LOCAL(408)269-2600 Sp qFe. LICENSED CONTRACTOR C.C.L.#427328
FAX(408)269-2650 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356
%ACKFLOW PREVENTION SPECIALISTS, INC.
MAILING/OWNER M&H Plumbing SERVICE Satellite Dialysis
Address ADDRESS
4718 Meridian Ave 10590 N Tan[au Ave
San Jose,CA 95118 Cupertino,CA 95014
CONTACT:George TEL# 408-280-7606
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts 009M2QT RP 2" A11474
NEW INSTALLATION: REPLACEMENT:
REPLACEMENT DEVICE INFORMATION
MANUFACTURER MODEL NUMBER - TYPE - - SIZE SERIAL NUMBER
LOCATION OF DEVICE
INTERNAL ❑ METER# 62109688 RIECEIVEt D
1
EXTERNAL® TAG# SEP 11007
Hazard TvOe: •k=* bRAVMW
• REDUCED PRESSURE DEVICES PRESSURE TYPE
Shutoff Valves
DOUBLE CHECK VALVES VACUUM BREAKERS
DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
AIR INLET CHECK VALVE
N0.1 N0.2 VALVE
#1 #2
CLOSED TIGHT ® CLOSED TIGHT ® OPENED AT 3.4 LBS. OPENED AT LBS CLOSED TIGHT❑ CLOSED TIGHT❑
INITIAL #lbs. 9.4 #lbs. OPENED UNDER 1.0 #LBS. LEAKED ❑ ❑
TEST OPENED UNDER 2.0 R DID NOT OPEN❑
LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT❑ CLOSED TIGHT ❑ kL9 CLOSED TIGHT❑
TEST #LBS #LBS OPENED AT_#LBS PENED AT #LBS CLOSED TIGHT❑ ❑
Comments:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE - PASS
CERTIFIED TESTER NO. 10866 DATE 9/4/07 FAIL
�ITIAL TEST B ❑
MO. DAY YR.
REPAIRED BY DATE
PASS ❑
FINAL TEST BY CERTIFIED TESTER NO. DATE FAIL ❑
MO. DAY YR.