2016_0120 IRRIGATION E'� DOMESTIC
FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �'� {�-2�-�( i4- 4t�'4't-/
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detectar
❑Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker 1=1Spi11-Resistant Pressure Vacuum Breaker
/ ,
Manufacturer�f � � Model Number �� Size 3` �t G
Located At ���� � Serial Number � ~ 2 3 �� ��
Is the assembly installed in accardance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight Y Closed Tig t � psid psid psid
Leakedf l Leaked❑ Did not open �.1 Did not open ❑ Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model l��"J ��'0-� SN: �l Z � �f
Date Tested for Accuracy: � �'—����
Remarks:
The above is certified to be true at the time of testing.
FirmName(�7�'� ��f�- ��• Firm Address ��C C�/ �'� �
Certified Tester(print) �� �'�N'0��'Certified Tester(signature)
Firm Phone#_ q�Z �6'� �� Cert.Tester No. �Q�Q���S'Z-- Date �— �� �
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy
GANDARA IRRIGATIOI� INC.
3901 Clifton D�. Richardson TX 75082
Office: 972-671-3776
Fax: 972-664-9158
. Cell: 972-467-391$
Emaii: eddiegan1@sbcglobal.net
917 SARATOGA WAY
BELMONT LANDING
COPPELL TX
To Whom it May Concern;
An irrigation system was installed at the property described above. In accordance with
the city of Coppell inspection requirements, we are providing the following information.
This irrigation systemhas been installedin accordance with all applicable
State and local laws,ordinances,rules,regulations and orders.
I have tested the system and determined that it has been installed according
to the irrigation plan and is properly adjusted for the most efficient
application of water at this time.
1 year warranty from the day of installation.
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P�..OF�TEX4s
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Sincerel .•••"'�P�.•�• '
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EDWARD GANDARA •M� ;��
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