2017_0130 .
- IRRIGATION DOMESTIC FIRELINE
The following form must be completed far 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: � �Z t P �'`�
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
❑Re uced Pressure Principle �"7Reduced Pressure Principle-Detector
oubleCheckValve CiDouble Check-Detector
❑PressureVacuumBreaker ��-iSpi11-Resistant Pressure Vacuum Breaker
Manufacturer �.lJ� �- (� � l�-� Model Number � � Size�1.��"
� i � �—r�
Located At '�"1�NC 1�1�1� Serial Number �- " / 1 Lf �� �
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 pened at Opened at Held at
Initial Test Closed Tight� Closed Tight _ psid psid psid
Leaked❑ Leaked'J Did not open '�-1 Did not open � Leakedl-I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight i�1 Closed Tight f J psid psid psid
Test gauge used:Make/Model �V't-�I� h�-�-4� SN: 3fZ� �
Date Tested for Accuracy: �C—��� �
Remarks:
The above is certified to be true at the time of testing.
Gandara Irrigak+on
3901 Cl�on Dr. Firm A ddress
Firm Name �?�c�r�r��,�,�,:,�;���„��
Certified Tester(print) �.l� �/Q'v �/���rt fied Tester(signature)
Firm Phone# !7 Z ��� 7 3�Z��Cert.Tester No.������� 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 IRRIGATION INC.
3901 Clifton Dr. Richardson TX 75082
Office: 972-671-3776
Fax: 972-664-9158
Celi: 972-467-3918
Email: eddiegan1@sbcglobal.net
818 PREAKNESS
COPPELL TX
To Whom it May Concern;
An irrigation system was installed at the property described above. In accordance with
the city of Coppell TX . 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 ��cP��.•��,rF
• +�
EDWARD GANDARA �:f' '
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