2013_0613 (11)CHECK ONE:
M-M
FIRELINE X
NANE OF PWS: CITY OF COPPELL
A IL
PWS I.D. #
LOCATION OF SERVICE:
'rhe
t. it prevention assembly detailed below has been tested and maintained as required by TNRCJ
regulations and is ccufled to be operating within acceptable parameters.
Serial Number Z eZ61 A 41
1,rA
The above is cadfied to be true.
Firm Name A, Catified Tester M 1),
r),
Firm Address Cat. Testa No. Date
Gauge# � 6 0 Y11 ? -/"
Date last accuracy tested
White - Customees Copy Yellow - City Copy Pink - Tester's Copy
— - - ------ ---- -
DC-Closed
Opened at
I
Tieht
sid
PP-----psid
Leaked
Did not Open
0
DC-Closed
()p en at
Ti&
psid
RP ----p
The above is cadfied to be true.
Firm Name A, Catified Tester M 1),
r),
Firm Address Cat. Testa No. Date
Gauge# � 6 0 Y11 ? -/"
Date last accuracy tested
White - Customees Copy Yellow - City Copy Pink - Tester's Copy