2015_1215 IRRIGATION DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
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: _� �A- C��
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
ClR�rd�nced Pressure Principle ❑Reduced Pressure Principle-Detector
zT ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker
�' �Q� � �i
Manufacturer � �C� Model Number V Size�_
Located At ���1'� r�..LJ Serial Number ��� �����
Is the assembly installed in accordance 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 TightLY Closed Tight.� psid psid psid
Leaked�] Leaked_� Did not open Cl Did not open f 1 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 ��� lZ�� SN: 3 j 2 ��
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
Firm Nam��""��"�"Y-r �IC �� Firm Address ��� ��/! ��� ��
.
Certified Tester(print) �� �����ertified Tester(signature)
Firm Phone# —/ ? � ��O� ��Cert.Tester No�P�3��Z Date_ r L����
* 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 IRRIGATION INC.
3901 Ctifton Dr. Richardson TX 75082
Office: 972-671-3776
Fax: 972-664-9158
Cell: 972-467-3918
� Email: eddiegan1 @sbcglobal.net
965 SARATOGA
BELMONT LANDING
COPPELL TX
To Whom it May Concem;
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.
Sincerely
EDWARD GANDARA --��
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