BACKFLOW (15)CERTIFICATION OF RE-CLAIMED WATER SYSTEMS�/�. CROSS CONNECTION SPECIALISTS
BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS �S
'�'1�►�Lj, INSTALLATION -REPAIRS -TESTING -CERTIFICATION
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BACKFLOW PREVENTION' SPECIALISTS, INC.
LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA'(ISOJAN
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3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 (408) 269"280
3808 FERNWOOD ST.. SAN MATEO CA 94403 FAX (406) 289- /k ! 9^f'A
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SERVICE ADDRESS 20400 Stevens Creek Blvd. Cupertino/X-De Anza Blvd 1BY:
MAILING ADDRESS PrometbeuS CONTACT MattHaft
20400 Stevens Creek Blvd. TEL# 679-2338
Cupertino, CA 95014
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Watts - — ----909QT - - -- - RP---- -11'. - --423618 - _.
INTERNAL ❑ TAG LOCATION OF DEVICE boiler make
EXTERNAL ❑
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS❑. FAIL❑.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE'
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INITIAL TEST BYh ..: CERTIFIED TESTER NO 9815 DATE. 12-23-03
ri3::" �. .:• • ..,_ c.:i o::,,,,;. ; ..-.i ?'.; L'. -:'MO. DAY YR.;
REPAIRED BY.... DATE
FINAL TEST BY
CERTIFIED TESTER NO.
DATE
MO. DAY YR.
REDUCED PRESSURE DEVICES
�„
PRESSURE TYPE ,;: •
DOUBLE CHECK VALVES
VACUUM BREAKERS------ -
RPP VALVES
DIFFERENTIAL
-
CHECK VALVE
CHECK VALVE
PRESSURE I RELIEF
VALVE
AIR INLET
CHECK VALVE
NOA
NO.2
CLOSED TIGHT ❑
CLOSED TIGHT ❑
OPENEDAT_LBS.
OPENEDAT_LBS
- CLOSED TIGHT ❑
INITIAL
# be.
# Ib&
#LBS
# LBS.
TEST
--
OPENED UNDER 2.0
OPENED UNDER 1.0
LEAKED ❑
LEAKED ❑
OR DID NOT OPEN ❑
OR DID NOT OPEN ❑
LEAKED ❑
REPAIRS
R11 f4
AND
MATERIALSb�`/
_.,.
USED
FINAL
CLOSED TIGHT
y
CLOSED TIGHT bl
2
CLOSED TIGHT ❑
TEST
#LBS -� .
#LBS /`
OPENED AT i��I.BS
OPENED AT _ LBS
# LBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE'
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INITIAL TEST BYh ..: CERTIFIED TESTER NO 9815 DATE. 12-23-03
ri3::" �. .:• • ..,_ c.:i o::,,,,;. ; ..-.i ?'.; L'. -:'MO. DAY YR.;
REPAIRED BY.... DATE
FINAL TEST BY
CERTIFIED TESTER NO.
DATE
MO. DAY YR.