Christopher BarrettT H C C I T Y• • or
OPPELL
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Clty of Coppell Pub11c Works Dept.
816 S. Coppell Road
Coppell, TX 75M
972462-5.50
www.coppelltx.gov
BACKFLOW REGISTRATION FORM
Regiatratlon is for one year from the date of registragon or ne-registretlon,
Name:
Physical Address:
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MaCArthur Gauge
MacArthur Gauge Inc.
1523 Baccarac Court
Euless, TX 76040
Instrument Calibration Report
Registration Information:
1-A Fire &Domestic Testing
PO Box 79548
Fort worth, TX 76179
Manufacturer: Mid -West
Model: 845-5
Serial Number: 10143252
Calibration Tag: 10143252
Type: Differential Other:
Gauge Tested Within Tolerances: Passed
Reference Pressure/Reading:
0 psi = N/A 5 psi = 5 10 psi = WA
1 psi = 1 6 psi = NIA 11 psi = WA
2 psi = 2 7 psi = 7 12 psi = N/A
3 psi = N/A 8 psi = WA 13 psi = NIA
4 psi = WA 9 psi = N/A 14 psi = N/A
15 psi = NIA
Calibration Date: 12/3/2018
Eires On: 1 2/312 0 1 9
This gauge is calibrated to an accuracy of +/- .2 PSID
All test instruments used in the calibration of this gauge conform to ASME 840.1 and are traceable to MI.S.T.
Service /Calibration Notes
Entry Type: RRR#R
NONE
Tested By: Zac Gates
Telephone: 817.685.0099 Fax: 817.283.1192 Web Site:
CERTIFICATE OF LIABILITY INSURANCE
DA7H(MMlQDlYYYYI
07/16/2018
THIS CERTIFICATE IS IS8UED A8 A MATTER OF INFORMATION ONLY AND CONFER8 NO RIGHTS UPON THE CERTIFICATE HOLDER. THI8
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE (88UING INSURER(8), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: H the CertItlCBte holder Is an I
terms and oondlttorle of fhe Polley, osrtaln
cerUflcate holder In tteu o! such endorsemel
PRODUCBt
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American National Jacoby Insurance
816 Towne Ct Suite 300
Saginaw, TX 76179
AL INSURED, the pollcy(laa) must t19 endorsed. h 8UBROGATION 18 WAIVED, subJoot to tho
may require an endoraomont A otstomont on this cortlBaate does not oontor rights to the
Mr Backflow dba 1-A Fire and Domestic Testing
117 S Hampshire St
Saginaw, TX 76179
CERTIFICATE NUMBER:
Brooke Jacoby _ . _..... _
817-308-7768 __---�1lIMl:. .. _._—.
_.. .._ INBURERIQ)AfiORAlIlOCdVERAOE _.__ ._. ... . i. HAICtl ...
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