625 Canterbury CITY OF CQPPELL WAT�R UTILITIES
CiJSTOMER SERVICE fN�SPECTI01`�
Residential [,�" CommesciaM ❑ TI�IRCC ID#057004�
I`
I �`��� �"r�� •��s``� u on ins ecti� o e
/ � ! � �� p��'x��wat�r dsstxiLution facilitiss lacaccd at
--- �`_ � ��t'"f _,., ,which is connecied to the City of Coppell WaTer System,do hereby ceztify
that,to the hest of my knowledge:
Tn Non- NIA
CampIiancs Cornpliance
(I� Na d�rect camaection beriueen t�e gublia drinking wat�r supply and a patentiai �/ � Q ❑
source of cantami.aation exisrs. Pofential sources af contarninatian are isolated ' '
from the public water system by an air gag or an apgrogriate baekfIow greue�tion
asse�nbly in accordance with Co�zmission regula�ons.
(Z} No crQss-connectian betwcen the pubiic drinkizzg water suppiy azzd a privai�vvater ' Cs��" p p
system exists,���Jhere an actual air gap is nat maintained betvreen the public water
supply and private water supply, au approved reduced pressure-zone h�ekf�ow �
, prevention assembly is proparly instafled and a s�rvice agreement exists for
annual inspectionand testing by a certi�ed�ackflotiv prevention device tester.
(3} t�Fo cnnnecrian e}cisis uJhicfi wnuld a�low tlie retum af�vater used£oz condensing � p �
} cooT�g or'sndus�al processes back t�the public water suppiy.
{4) No pipe orpzpe fitting v�rb,ich contains mare than 8,Q°!a lead exists ix�private water �" p �
disiziburian facilities installed an or aft�r.July I, 1�88. ,
{�} Na solder or flux w�ich cont.ains more than �.2°/a lead exzsis in pri�ate water C�/ � p � p
distrz'burion f�cilities inst�ed on or after July I,1�88.
Y•' �
Water service sha11 nat be pmvided or restored to the private water distribuCion facili,des unti,l the above ennditi.ons are deta�znined to be
iu compliancc.
I certify that the fallawing materials wifl6e used in the installati�m of the grivace vvatez d�sm'bu#zon facilities lr5cated at
���-.f^�-�tw,y . •-•---------aud that the inspector will validate compliance dtuiug the inspectian process;
Service Iines Lead ❑ Cogpec ❑ PVC ' ❑ p��r �
�QF��� Lead ❑ X.ead Frcc �'' Soivsnt Weld O Other Ll
k."
T recggnize that this document shail become a pezmazseni rc�ord of the aforementioned Pt�blic Water System an3 that I axn Iegally
responszb for the valitlity of the infom�xation I have prnvided.
. ' �, �""
Signature of Lice d Plumber Re�ist�ation�N'um.be�
�,1:�P.� ��-
Type af Registrarion Date
I recognize that•this docu�i�;ent shatI�e�ome a pecmanen.t zecord of the aferementianed Public Water System aad Ehat I am legally
r�spon ' ie for the validity of the infaiznabon provi$ad.
���
Signa[are of Z pectar RegisGalion Number
��"� � ._ d��� i� �
Type of Re�is�-atien Date
1Vhia-Cus[amers Coyy YtElOw-Cit�.S Capy Pinlc-[asPecfofs CaAY