2013_0131'Water service. &WI not be provided or restored to the private water distribution facilities until the above conditions are determined to hoc
in compliance,
I ca* that the folloua�itig'Maftrials will be used in the installau0n Of the Private water distribution facilitlks located at. Z/S-
4 and that the inspector Will validate compliance during the insp=tion. process:
S_C►jce lines Lead 0 Copper 13 PVC Odw
a21—der Lead 13 Lead Free E3 Solvent Weld 0 Otber JK
1 recognize that this document shall become a per.manent record of the aforementioned Public Water System and that I am legally
resPOnsib for Vali I of the information I have provided,
Signature of Licensed Plum—her Registration Number
Type of Registration Date
I recognize that this document shall become 2 permanert record of the aforementioned Public Water System and that I am legally
responsible r,
sPORs' e Or e 'ali itY of the infb=ation provided.
S at
ure
. of
ignaturt of pector Registration Number
Typi-of Rlgiltm�tion
Date
P=k - is PMOrs Copy
CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential 0 Commercial ri
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:
Non. N
(1)
No direct connection between the public drinking water supply and a potentw
Coyliance Compliance
0
source of contamination exists. potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow:prevenfion
assembly in accordance with Cornut ssjonrcgulations.
(2)
No cross-connection between the public drin�' g winter Supply and I a Private Water f
[3
system exists, Where an actual air 9ZP is not maintained between the public water
supply and private water supply, an approved reduced prcst;ure-zone backflow
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified bacUow prevention device tester,
(3)
No connection exists which would allow the return of water used for condensing
Li l
cooling or industrW processes back to the public water supply.
(4)
No pipe or pipe fitting . which contains more d= 8.0% lead exists in private water
distribution facilities instilled on or after July 1, 1988,
(5)
No solder or -flux which contains more than 0.2% lead exists in private water
ri 0
distribution facilities installed on or after July 1, 1989.
'Water service. &WI not be provided or restored to the private water distribution facilities until the above conditions are determined to hoc
in compliance,
I ca* that the folloua�itig'Maftrials will be used in the installau0n Of the Private water distribution facilitlks located at. Z/S-
4 and that the inspector Will validate compliance during the insp=tion. process:
S_C►jce lines Lead 0 Copper 13 PVC Odw
a21—der Lead 13 Lead Free E3 Solvent Weld 0 Otber JK
1 recognize that this document shall become a per.manent record of the aforementioned Public Water System and that I am legally
resPOnsib for Vali I of the information I have provided,
Signature of Licensed Plum—her Registration Number
Type of Registration Date
I recognize that this document shall become 2 permanert record of the aforementioned Public Water System and that I am legally
responsible r,
sPORs' e Or e 'ali itY of the infb=ation provided.
S at
ure
. of
ignaturt of pector Registration Number
Typi-of Rlgiltm�tion
Date
P=k - is PMOrs Copy