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"�'" CITY QF COPPELL WATER UTILITIES
CUSTOMER SE'IrVYC'E INSPECTIOr
, � � , , : „"Ir.��,� <; *'`
Residential C� Co 'mmercial ❑ �R� D#0570040
I _;c:� .� . ?�'G-k r���.:"a�' ,upon inspection of the pribate water distribution facilities located at
"��'C' �' . ,�-.I�rn/ , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compliance Compliance
(1) No direct connection between the public drinking water supply and a potential Q� ❑ Q.F<
source of contamination exists. Potenrial sources of contam�nation .are isolated
�,_:. :
from the public water systern by an air gap or an appropriate backf�ow preventi�ti� ' �
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking water supply and a private water [�' ❑ ❑
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 ass�nbly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
-,:ti,�;
(3) No connecrion exists which would allow the retum of water used for condensing �' p ❑
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 pnvate water (a'� ❑ ❑
distriburion faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water C� Q ❑
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 condirions are detemuned to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion faciliries located at
�7b �'. �t ttt I�!� ('e:,+�EtL, T�r and that the inspector will validate compliance during the inspecrion process: '
Service lines Lead ❑ Copper � PVC ❑ Other LR�
ySolder Lead ❑ Lead Free C�"' Solvent Weld O Other ❑
�r�I recognize that this doeument shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
; � _ ,� ��' "��' ��3 �•+'.�",�.�3'
Sig re of Licensed Plumber Registration Number
'�.' �,��rr �"* r4' ,��r,s.�f�.•,,"c 1�'�,�'�`,,;�i �► �r,�a�rFr r�
Type of Registrarion 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 informarion provided.
Signature of Inspector .,�,.: Registration Number
Type of Registration � ` Date
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White'.-Customers CoPY`" Yelbw-Ciry's CoPY Pink-Inspeaors CopY
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