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BACKFLOW (13)CERTIFICATION OF RE-CLAIMED WATER SYSTEMS �°tl4 CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANT' a S �I INSTALLATION -REPAIRS -TESTING -CERTIFICATION %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 3608 FERNWOOD ST., SAN MATEO CA 94403 FAX (408) 269.2650 • SERVICE ADDRESS 20400 Stevens Creek Blvd., Cupertino/X-De Anza Blvd MAILING ADDRESS PrOmetheus CONTACT BOB 20400 Stevens Creek Blvd TEL# 410-6517 Cupertino, CA 95014 MANUFACTURER MODEL NUMBER TYPE Febco 805Y DC SIZE SERIAL NUMBER f/arfir8o z^ 1� INTERNAL,,'�� TAG LOCATION OF DEVICE chiller make up EXTERNAL %�E%atrq�— $�-r.T/�� IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX E3 PASS FAIL❑ THE ABOVE REPORT 18 CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE • REPAIRED BY `S'gA FINAL TEST BY CERTIFIED TESTER NO. DATE 1-24-05 MO. DAY YR. MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE / RELIEF VALVE AIR INLET CHECKVALVE NO.1 NO.2 CLOSED TIGHTA CLOSED TIGHT OPENED AT _ LBS. OPENED AT LBS CLOSED TIGHT ❑ INITIAL 0lbs. A b # lbs. /I -( _ OLBS 0 LBS, TEST OPENED UNDER 2.0 OPENED UNDER 1,0 LEAKED Cl LEAKED Cl OR DID NOT OPEN ❑ OR DID NOT OPEN Cl LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT❑ TEST OPENED AT _LBS OPENED AT_LOS #LBS PUBS #LBS THE ABOVE REPORT 18 CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE • REPAIRED BY `S'gA FINAL TEST BY CERTIFIED TESTER NO. DATE 1-24-05 MO. DAY YR. MO. DAY YR.