633 Canterbury C�TY OF CQPPELL WATER UTILITIES
CUSTOMER SERVICE.�I`�SPECTI.UIti
Residential � Commercia! � TNRCC ID#U574U4Q
I /�' a�� �" ��`� u .n ins ection of the
, po p pnvate water dish-�but�on facihnes located ac
L��� C19'�V'I Cr' '�jc� (`�.f tivhich is coaneaied tQ the Cxty of Coppell Water System,do hereby certify
that,ta the best of my k.nowledge:
� 1*1an- N1.A
Compliance Compliance
(1) No direct con�eotian between the public drinking water supply and a potential � ' ❑ ❑
saurce of contamination exists. Potential sanr�es af cont�emiaa�ion sue �so]ated ' '
fram the public water system by au air gap or an apgrnpriate backflow prevention
assemhly in accordance with Cotrunission regulatians.
(2) No cross-connecEion b�tween the pul�tic clrinkuig water sugply and a private water ` [� p p
system exists.� tiVhere an accual ai�gap is not maintained.ba.tween the publia water
sapply and private water supply, an approved rednced gressiireraone bacicflow �
, preventiou assembly is properly instalied and a service agreement exists for
annnal iuspec#ion.and testing by a certi�ed backflaw prevention device tester:
(3) N�connection exists which would allow thc return of water used for condensin� �' [� ❑
� �oqTiz�g or industrial processes back ta t�e public water supply,
(4) No pipa or gipe fitting which contains more than 8,0°JQ lead exisis in pri�ate water � � p p
distribution facilities installed on ar after.7ul}�I,1988. ,
�5) No solder or tlux w3�ich cantains mare than 0.2°/a lead e+cists in private water �/ � p • . p
distribution facilities installed on or after July 1,1988.
.. •
Water service shall not be provided or restored to tbe private�ater distrihution facilities until the above eandition�are dctenmitaed to be
in cvrnpliance.
I certify that the fallawing materials wi11 be used in the installatian of[he.priv�Ee water distribution f.acilities 16cated at
and that the inspectpr wili vaiidate compliance during the inspectia�process:
.
Seivice lines Lead ❑ Cogper ❑ PVC ' t� Q��r �
Solder �.ead CI �:�ad FzQa �'` Snlvent Weld ❑ DClier T�1
y..
I recn��nize that this dacument shall become a permanent record of the aforemention�d Fut�lit Water Systcm and tl�at I am l�gally
responsib for che validity of the information I have provided.
, �, _� � ��
Signature of T.ice�d Plumber Re isi=atj �,Numbe�
����. � � �
Typa of Registrafion D te
�recognize that•this document shall become a permanent record of.thc aForementioned Public Water System and fhat I am legally
respon " ie for the vglidity of the infonrcati�n provided.
� ���
Signature of� pector R��istratio Number
! � �/� ��
Typa �f Registration Da— t�
u'hitc-Customers Cupy Ye►Iaw.CitY.s Co�y Pink-InspCClofs Copy