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 � �4 �L �A- �/►a
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 �iReduced Pressure Principle-Detector
�ouble Check Valve :1 Double Check-Detector
❑PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��Ll�N_� Model Number 3 � Size�
Located At '���—��� � � 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 Tighti- Closed Tight psid psid psid
� Leaked�:i Leaked'� Did not open C� Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model �ti���� SN: ��2 d �
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
FirmName�1fQJ��1�I�IA � �iC. Firm Address 3 �C�C G(�j� '`J �Y�
Certified Tester(print) �� � }��V QJ4-�/�ertified Tester(signature)
Firm Phone#� 7 Z �(z �� ��Cert.Tester No.���3��Z Date ! '—/ �/ 7
* 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
837 SARATOGA
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
EDWARD GANDARA ��,��,a�.r��
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