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BACKFLOW (5)CERTIFICATION OF RE-CLAIMED WATER SYSTEMS Sap CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS • BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION PRESSURE TYPE %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 FAX (408) 269.2650 3608 FERNWOOD ST., SAN MATEO CA 94403 is SERVICE ADDRESS 20400 Stevens Creek Blvd., Cupertino/X-De Anza Blvd MAILING ADDRESS Prometheus CONTACT Bob 20400 Stevens Creek Blvd., #245 TEL# 410-6517 Cupertino, CA 95014 MANUFACTURER MODELNUMBER TYPE Watts INTERNAL 0 - EXTERNAL ❑ 909QT RP SIZE SERIAL NUMBER 1„ 3670iT 423618 TAG LOCATION OF DEVICE boiler make up Aol:,O� IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX❑ PASS FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER N0. 2656 DATE 1-21-05 . REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. MO. DAY YR. 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 CHECKVALVE N0.1 N0.2 UU CLOSED TIGHDAfr CLOSED TIGHT OPENED AT7;8 LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL # IOa. ";f IF IDe. #LBS # LBS. 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 ❑ CLOSED TIGHT El TEST OPENED AT_LOS - OPENED AT _LBS #LBS tLBS tLBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER N0. 2656 DATE 1-21-05 . REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. MO. DAY YR. DATE MO. DAY YR. CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS-, BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION �.ai!/its 9r6• . PRESSURE TYPE %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 FAX (408) 269.2650 3608 FERNWOOD ST., SAN MATEO CA 94403 DIFFERENTIAL SERVICE ADDRESS 20400 Stevens Creek Blvd., Cupertino/X-De Anza Blvd CHECKVALVE MAILING ADDRESS Prometheus CONTACT Bob 20400 Stevens Creek Blvd., 4245 TEL# 410-6517 Cupertino, CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Febeo 805Y DC I" U1365 INTERNAL' TAG LOCATION OF DEVICE chillier make up 41 p EXTERNAL S�ad�.G GG elf, Ba�Sed o� p�--y/-u 0-4:7 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX [3 PASS)Q FAIL❑ THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 1-21.05 MO. DAY YR. REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO.: DAV YR. I REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECKVALVE CHECK VALVE PRESSURE I RELIEF VALVE AIR INLET CHECK VALVE NO.1 NO.2 CLOSED TIGHT CLOSEDTIGHT OPENEDAT_LBS. OPENED AT LBS CLOSEDTIGHT Cl # Ib#. 116 A � #LBS INITIAL it Ibs. $LSS. 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❑ OPENED ATLBS OPENED ATLBS TEST #LBS #LBS _ _ #LBS THE ABOVE REPORT IS CERTIFIED TO BE TRUE INITIAL TEST BY CERTIFIED TESTER NO. 2656 DATE 1-21.05 MO. DAY YR. REPAIRED BY FINAL TEST BY DATE CERTIFIED TESTER NO. DATE MO.: DAV YR. I