2012_1220 (2)CITY 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 the installation of the private water distribution facilities located at
Service lines Lead ❑ Copper
Solder Lead ❑ Lead Free
and thal, the inspector will validate compliance during the inspection process:
PVC Other ❑
Solvent Weld Q' Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
resp risible for the v lidi of the information I have provided.►^
Sign re of L' ensed lumber Registration Number
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 in"ation provided.
Signature of Inspector Registration Number
Type of Registration
Date
White - Customers Copy Yellow - City's Copy Pink - Inspectors Copy
Residential ❑ Commercial ❑'
TNRCC ID ##0570040
I
t , upon inspection of the private water distribution facilities located at
114
3 e o7 O I 77* which is connected to the City of
Coppell Water System, do hereby certify
that, to the best of my knowledge: a
In Non- N/A
Compliance Compliance
(1)
No direct connection between the public drinking water supply and a potential
Q'v ❑ ❑
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
t
Cy ❑ ❑
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
❑ ❑
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
Service lines Lead ❑ Copper
Solder Lead ❑ Lead Free
and thal, the inspector will validate compliance during the inspection process:
PVC Other ❑
Solvent Weld Q' Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
resp risible for the v lidi of the information I have provided.►^
Sign re of L' ensed lumber Registration Number
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 in"ation provided.
Signature of Inspector Registration Number
Type of Registration
Date
White - Customers Copy Yellow - City's Copy Pink - Inspectors Copy