2017_0111 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: °�� j�1�T�G �q,
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
�❑ duced Pressure Principle C�Reduced Pressure Principle-Detector
ouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker rSpill-Resistant Pressure Vacuum Breaker
� ' � � �� C�
Manufacturer �1 �- �' (��odel Number � Size�
A -(�Z�3 �
Located At �� ��l�C.Q'�� Serial Number ���' �� ���j
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 Tight' Closed Tight � psid psid psid
Leaked'7 Leaked❑ Did not open ��� Did not open !� Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I I Closed Tight�:! psid psid psid
Test gauge used: Make/Model �ati� [Z 1�-�' SN: 3�2 ��
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
Firm Name���� (2�r ��-`�, Firm A ddress �(� l GL'1 ��
Certified Tester(print) �� C7 '����ert f�d Tester(signature)
Firm Phone# �7 Z `L�����ert.Tester No.���3��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 IRRIGATION INC.
3901 Clifton Dr. Richardson TX 75082
Office: 972-671-3776
Fax: 972-664-9158
Cell: 972-467-3918
Email: eddiegan1@sbcglobal.net
841 SARATOGA
COPPELL TX
To Whom it May Concern;
An irrigation system was installed at the property described above. In accordance with
the city of Coppetl 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 property adjusted for the most efficient
application of water at this time.
1 year warranty from the day of installation.
Sincerefy
EDWARD GANDARA y���E�OF�F
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