2013_0220CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential ❑ Commercial M I TNRCC ID #0570040
I .Noe— A(d6y- e , upon inspection of the private water distribution facilities located at
143 S hny4tj la &J I,k 0 1x0 , which is connected to the City of Coppell Water System, do hereby certify
that, to the best of my knowledge:
In Non- N/A
Compli ce Compliance
(1) No direct connection between the public drinking water supply and a potential l ❑ ❑
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.
1
(2) No cross - connection between the public drinking water supply and a private water l ❑ ❑
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 0// ❑ ❑
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 ❑ ❑
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 ❑ ❑
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 the installation of the private water distribution facilities located at
1413 S. be^WoA SO Rd Sude W 110 and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper l3 PVC C Other ❑
Solder Lead ❑ Lead Free Q' Solvent Weld ❑ Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res onsible for the lidi of the information I have provided. la�� 114 ILI 13cl
Sig a re of License Plumber Registration Number
Type of Registration Date
I recognize that
of
Type of Registration
0it shall become a permanent record of the aforementioned Public Water System and that I am legally
of the information provided.
White - Customers Copy Yellow - City's Copy Pink - Inspectors Copy