131 Trinity Ct Residsutial � Commercial ❑ "I:ti'RCC ID it05700�0
1 � ,upon uupe�;tioa uf die pn.�a�e wa�u disoribution facilities Ic�ca��d at
. which is connected t� thr C'in•of Coppell Water System do 6enbvi certify
that,to the bat of my lmowledge:
ln *lon- '��A
Comp2iaac� Compliaace
(1) No direct :onnec5oa berx•cen the public driakiag aater supply aad a potens:a'. � p p
source of contamiaa�on cxisu. Potential sources of contaminaaon ;se isolaud
Erom tt►e public watu sysiem by an air gap or aa appropriaic baclilou� prc�•cntioa
assembly in acco�daace w�t6 C.�u�uiission reguiatioos.
�2) No aoss-connecuon bctween the public drinking water supply aud a privat� wata � O u
system taists. Wherc an sctual air gap�s nw maintained between the pubiic watcr
su�ply and pnvau wster su�ply, m approved reduced pressure-zone backflow�
prcveation assernbly u properfy mso�lled a� a semce agretment cxut5 for
anaual iaspeeuon and test�ag by a ctrofied bacicflow prcvenhon dev�ce tester.
(3) No coonection exists which would aUow the retutn of water used for condensing '� Q p
cooling or industrial processes back to the public water supply.
(4) No pipe ar pipe fitting whicb contains more than 8.0%lead exists in private water ,� p ❑
distnbution facilities instalitd on or after Julv 1. 1988.
(5� No solder or flux which c�ntains rtx�rc than 02°� lead exists in omate water .�,0 ❑ p
distr�bution facilitie�install�d on c►r aRrr Julv 1 19RR
Wata sen�ice sball not be proti7ded or rtstorcd to the prisatt�4•a!r. �+is*i�utie�tacilit�cs:�ti!the aM��e:ondi+�o�se de!cimined to bc
ia compliancc.
I certify that iLe follow� g materul, ill be us�;d iu the iusiillition of thc pri►ate kater discib�;t;on.atLities 1oau3 ai
�—
1� ( ____ and that the inspector will validate compiiance durmg the inspection pr+ocess�
Ssrv�ce luus Lead D Copper u r V t, u t)tner S- /E�
Solder Lead O Lad Free 0 Solvent 1A�etd ❑ Other y�
I recogaiu that this document shaU become a perrrnnrnt raord of the aforementioned Public Water System and tbat I am legally
r �bk for tLe validiry of the informaaon 1 haye provided.
+ `� �� � �7 � r �-7
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Sig re of Licensed Plum Reeistration NumF+er
`itiit� ! ` + 31- 1(�
Type oCRegistration iia�r
I recogaue that thrs docuaxnt shaU become a parnanent record oi Ct�e afonmennoned Wouc Water�ystem and that 1 un legaliy
�s�'at�ble for tbe wl�ry ot the mformaaoa�rov�dS,A.
I � �.--, //� "'_ .�4 ���
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,
S�gn re of Inspector Registration Number
���� � �, ! � -3 �— Ic�
Typc of Regis�at�on Da;;,
W�1r•Qweqlert Caov ye�rr.Cm a l''.t�. vinl-�e.Me+n.s rrq..