560 Heritage Oak CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential Commercial ❑ TNRCC ID#0570040
I /�(��r`.�. �a_.��� �. ,upon inspection of the prn�ate water distribution facilities located at
S�p `� � �����r,�_ da.�,_. �, aT 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 potenrial O ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water Q ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing C�J ❑ ❑
cooling or indus�ial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water � p ❑
dis�iburion faciliries installed on or after July 1, 1988.
5 No solder or flux which contains more than 0.2% lead exists in rivate water � ❑ ❑
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distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution faciliries until the above conditions are determined to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion facilities located at
rG O ��dr-•�t-�r c�e.v`_ c� _ and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper O PVC O Other C� ��
Solder Lead ❑ Lead Free ❑ Solvent Weld ❑ Other l� ��'�('
I recognize that t ' oc become a permanent record of the aforementioned Public Water System and that I am legally
responsib� validity of the info 'on I have provided.
SZ\'�2 b
Signature of Licensed umber Registration Number
�.d r.(,,,, . � 3/ \f'
Type of Registration�� Date
I recognize that this do ent shall become a petmanent record of the aforementioned Public Water System and that I am legally
responsible for idity of the�nfrt�a*��n�rovided.
�.---_
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Signatur f Inspect ,__ - � Registration Number
� �?/�/1 �
Type of Registration ' Date
White-Customers Copy Yellow-Ciry's Copy Pinlc-Inspeaors Copy