938 Snowshill t���,r;f-# ��'- /`�-3//g
CITY OF COPPELL WATER UTILITIES
� CUSTOMER SERVICE INSPECTION
Residential Commercial ❑ TNRCC ID#0570040
I � /�d� ,upon inspection of the pri��ate water distriburion facilities located at
g,����ti�L�;�( , 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 e Compliance
(1) No direct connection between the public drinking water supply and a potential � ❑ ❑
source of contamination exists. Potenrial 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 [Y O ❑
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 assembly is properly installed and a service agreement exists for
annual inspection and tesring by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the return of water used for condensing C�Y p ❑
cooling or indusuial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water 0' ❑ ❑
distribution facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water B� O ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution faciliries unril the above condirions are determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution facilities located at
�3� .���s�;�� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead O Copper � PVC [�' Other C� �/�
older Lead � Lead Free [� Solvent Weld � Other ❑
I recognize tha ocument shall come a permanent record of the aforementioned Public Water System and that I am legally
responsib ' ity of ormation I have provided.
,�-3�y75
Sig re o ensed umber Registration NumbeF
��S'�� �'2�- �5
Type of Registration 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 information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customers Copy Yellow-Ciry's Copy pink-Iaspeaors Copy