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BACKFLOW REPORTS CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS $ ♦ .,-„ ,,�,„-„� BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTIONV'! PREEVENTION ANTS :y, ;,> � INSTALLATION-REPAIRS-TESTING-CERTIFICATION %ACKFLO 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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 11010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Barry 680 Quinn Ave TEL# 971-2445 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825Y RP 2" BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 by pump#3 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX(3 PASSTA FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE ,y CLOSED TIGHT gI CLOSED TIGHT �I OPENED AT dn•UQp LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #Ibs. #lbs. #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED Cl REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT Cl CLOSED TIGHT ❑ CLOSED TIGHT Cl TEST pLBS #LBS OPENED AT LBS OPENED AT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY/ 6 CERTIFIED TESTER N0, 10466 DATE 07-14-06 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS QK °m,.— CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ',,r' BACKFLOW PREVENTION VALVE EXPERT '. INSTALLATION-REPAIRS-TESTING-CERTIFICATION IL L � .: %ACKFL EVENTION SPECIALI=+LOW�3569)LICENSED CONTRACT R C.C.L.#427328 CALIFORNIA (800)43750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS..1 1010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quinn Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Pebco 765 PVB 11/2" AA9694 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 by pump#3 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT_LBS. OPENED AT`j_8 LBS CLOSED TIGHT L6. INITIAL p lbs. #Ibs. #LBS #LBS. 4.4 TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT Cl CLOSED TIGHT❑ OPENED AT LES OPENED AT_LBS ' TEST pLBS ALBS pLBS ' THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 10466 DATE 7-14-06 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION • S+M�viCteta��M' BACKFLOW 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- 3608 408)269.2600 F.�.C.'.�t2003 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-26 R SEP 2 4SERVICEADDRESS 11010 N De Anza Blvd.,Cu rtino/X-HomesteadMAILING ADDRESS Service Station Systems CONTACT 680 Quinn Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 765 PVB l 1/2" AA9694 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX(:I PASS❑ FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL - CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT_LBS. OPENED AT I.v LBS CLOSEOTIGHT INITIAL Nibs. 0lbs. #LBS 0 LBS. A-0 TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT Cl CLOSED TIGHT❑ TESTOPENED AT_LBS OPENED AT_LBS #LBS ALBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 9815 DATE 9-18-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS . .�e. BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW 3 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 e.�'_F_ TVEi D 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-26 SERVICE ADDRESS 11010 N De Anza Blvd.,CIL eTtino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quitm Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE. SERIAL NUMBER Febco 825Y RP 2° BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS I FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF N0.1 ��{{ � N0.2 VALVE AIR INLET CHECK VALVE CLOS/ED TIgG}IT LSI - CLOSED TIGHT OPENED ATaC6S. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #lbs. P O II'' ,#lbs. #LBS #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 ❑ CLOSED TIGHT❑ TEST OPENED AT_LBS OPENED AT_LBS #LBS #LBS #LBS - THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY �J • Y wlK�(J"'C! CERTIFIED TESTER N0. 9815 DATE 9-18-03 MO.. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT mfr INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW 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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 11010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quinn Ave VTEly�,971.0135 San Jose,CA 95112 r 200 MANUFACTURER MODEL NUMBER FTYPE SIZE SERIAL NUMBER - Febco 825Y Z° BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 F(,�177 T' 3 EXTERNAL /e�lacedya -'03 4,s re, ns �l% si�ILJ( d �s re0 CA) IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FA REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECKVALVE CLOSED TIGHT L1 CLOSED TIGHI ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT U INITIAL #lbs. #lbs. pr# j1^ #LBS #LBS. TEST PEND UNDER 2.0 OPENED UNDER 1.0 LEAKED LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED Cl REPAIRS lPjo%>Ced /`end re�rop AND '� y�� • ' /L MATERIALS Pl..s...� C6(cs-� t/o, / USED �' FINAL CLOSED TIGHT CLOSED TIGHT OPENED AT y LBS OPENED AT_LBS CLOSED TIGHT Cl TEST #LBS 8,c) #LBS ALBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE I INITIAL TESTS .._ CERTIFIED TESTER N0. 10220 DATE 3-15-05 L/ ....._ MO. DAY YR. •REPAIRED BY b DATE '/ FINAL TEST BY CERTIFIED TESTER NO. DATE y-Jr 'C/y DI..( MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT mfr INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW 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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 11010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quinn Ave VTEly�,971.0135 San Jose,CA 95112 r 200 MANUFACTURER MODEL NUMBER FTYPE SIZE SERIAL NUMBER - Febco 825Y Z° BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 F(,�177 T' 3 EXTERNAL /e�lacedya -'03 4,s re, ns �l% si�ILJ( d �s re0 CA) IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[] PASS FA REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECKVALVE CLOSED TIGHT L1 CLOSED TIGHI ❑ OPENEDAT_LBS. OPENEDAT_LBS CLOSEDTIGHT U INITIAL #lbs. #lbs. pr# j1^ #LBS #LBS. TEST PEND UNDER 2.0 OPENED UNDER 1.0 LEAKED LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED Cl REPAIRS lPjo%>Ced /`end re�rop AND '� y�� • ' /L MATERIALS Pl..s...� C6(cs-� t/o, / USED �' FINAL CLOSED TIGHT CLOSED TIGHT OPENED AT y LBS OPENED AT_LBS CLOSED TIGHT Cl TEST #LBS 8,c) #LBS ALBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE I INITIAL TESTS .._ CERTIFIED TESTER N0. 10220 DATE 3-15-05 L/ ....._ MO. DAY YR. •REPAIRED BY b DATE '/ FINAL TEST BY CERTIFIED TESTER NO. DATE y-Jr 'C/y DI..( MO. DAY YR. CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS $ ♦ .,-„ ,,�,„-„� BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTIONV'! PREEVENTION ANTS :y, ;,> � INSTALLATION-REPAIRS-TESTING-CERTIFICATION %ACKFLO 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 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS 11010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Barry 680 Quinn Ave TEL# 971-2445 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 825Y RP 2" BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 by pump#3 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX(3 PASSTA FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE ,y CLOSED TIGHT gI CLOSED TIGHT �I OPENED AT dn•UQp LBS. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #Ibs. #lbs. #LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED Cl REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT Cl CLOSED TIGHT ❑ CLOSED TIGHT Cl TEST pLBS #LBS OPENED AT LBS OPENED AT_LBS #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY/ 6 CERTIFIED TESTER N0, 10466 DATE 07-14-06 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS QK °m,.— CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS ',,r' BACKFLOW PREVENTION VALVE EXPERT '. INSTALLATION-REPAIRS-TESTING-CERTIFICATION IL L � .: %ACKFL EVENTION SPECIALI=+LOW�3569)LICENSED CONTRACT R C.C.L.#427328 CALIFORNIA (800)43750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-2650 SERVICE ADDRESS..1 1010 N De Anza Blvd.,Cupertino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quinn Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Pebco 765 PVB 11/2" AA9694 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 by pump#3 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX[3 PASS FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT_LBS. OPENED AT`j_8 LBS CLOSED TIGHT L6. INITIAL p lbs. #Ibs. #LBS #LBS. 4.4 TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT Cl CLOSED TIGHT❑ OPENED AT LES OPENED AT_LBS ' TEST pLBS ALBS pLBS ' THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 10466 DATE 7-14-06 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION • S+M�viCteta��M' BACKFLOW 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- 3608 408)269.2600 F.�.C.'.�t2003 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-26 R SEP 2 4SERVICEADDRESS 11010 N De Anza Blvd.,Cu rtino/X-HomesteadMAILING ADDRESS Service Station Systems CONTACT 680 Quinn Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febco 765 PVB l 1/2" AA9694 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX(:I PASS❑ FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL - CHECK VALVE CHECK VALVE PRESSURE/RELIEF N0.1 N0.2 VALVE AIR INLET CHECK VALVE CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT_LBS. OPENED AT I.v LBS CLOSEOTIGHT INITIAL Nibs. 0lbs. #LBS 0 LBS. A-0 TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN Cl OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT❑ CLOSED TIGHT Cl CLOSED TIGHT❑ TESTOPENED AT_LBS OPENED AT_LBS #LBS ALBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 9815 DATE 9-18-03 MO. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. CROSS CONNECTION SPECIALISTS CERTIFICATION OF RE-CLAIMED WATER SYSTEMS . .�e. BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS INSTALLATION-REPAIRS-TESTING-CERTIFICATION BACKFLOW PREVENTION SPECIALISTS, INC. LICENSED CONTRACTOR C.C.L.#427328 CALIFORNIA (800)464-FLOW 3 3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 (408)269-2600 e.�'_F_ TVEi D 3608 FERNWOOD ST.,SAN MATEO CA 94403 FAX(408)269-26 SERVICE ADDRESS 11010 N De Anza Blvd.,CIL eTtino/X-Homestead MAILING ADDRESS Service Station Systems CONTACT Karen 680 Quitm Ave TEL# 971-0135 San Jose,CA 95112 MANUFACTURER MODEL NUMBER TYPE SIZE. SERIAL NUMBER Febco 825Y RP 2° BA8741 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 19780709 EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS I FAIL❑ • REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE I RELIEF N0.1 ��{{ � N0.2 VALVE AIR INLET CHECK VALVE CLOS/ED TIgG}IT LSI - CLOSED TIGHT OPENED ATaC6S. OPENED AT_LBS CLOSED TIGHT ❑ INITIAL #lbs. P O II'' ,#lbs. #LBS #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 ❑ CLOSED TIGHT❑ TEST OPENED AT_LBS OPENED AT_LBS #LBS #LBS #LBS - THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY �J • Y wlK�(J"'C! CERTIFIED TESTER N0. 9815 DATE 9-18-03 MO.. DAY YR. • REPAIRED BY DATE FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR.