2013_0812CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Water service shall not be provided or restored to the private water distribution facilities until the above conditions are determined to be
in compliance.
I certify that the following materials will be used in th installation of the private water distribution facilities located at
A) C,1" d and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC 1K Other
Solder Lead ❑ Lead Free lirr Solvent Weld 4 Y' Other
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
Signatur of Licensed Plumber Registration Number
rst,,-,,j �& --N-.j '9 -12 Zy��
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White - Customers Copy Yellow - City's Copy Pink - Inspector's Copy
Residential 0/ Commercial ❑
TNRCC ID #0570040
upon inspection of the private water distribution facilities located at
which is connected to the City of
Coppell Water System, do hereby certify
that,
to the best of my knowledge:
In Non- N/A
Comph ce Compliance
(1)
No direct connection between the public drinking water supply and a potential
❑ ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2)
No cross - connection between the public drinking water supply and a private water
19/ ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure -zone backflow
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3)
No connection exists which would allow the return of water used for condensing
C ❑ ❑
cooling or industrial processes back to the public water supply.
/
(4)
No pipe or pipe fitting which contains more than 8.0% lead exists in private water
L ❑ ❑
distribution facilities installed on or after July 1, 1988.
(5)
No solder or flux which contains more than 0.2% lead exists in private water
�/
[1] ❑ ❑
distribution facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities until the above conditions are determined to be
in compliance.
I certify that the following materials will be used in th installation of the private water distribution facilities located at
A) C,1" d and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC 1K Other
Solder Lead ❑ Lead Free lirr Solvent Weld 4 Y' Other
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
Signatur of Licensed Plumber Registration Number
rst,,-,,j �& --N-.j '9 -12 Zy��
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White - Customers Copy Yellow - City's Copy Pink - Inspector's Copy