610 Westhaven CITY OF CCIPPELL WATER UTILITIES
CUSTQMER SERVICE�NSPECT10Pv
Residential � Cnmmercial � TNRCC ID#0570Ud4
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1 ,upon ins'ection�f the private water distribution facilicics located at
� ,wh�ch is connecied to She City of Coppelt Water System, do hereby certify
that,co the besf of my knowledge:
In Non- A!!A
Compliance Complianee
(1) Na direct con�ectian between tbe public drinking water supply and a potential �'' ' ❑ ❑
saurce of contamination exists. Potential sources of contamination are isolated ' '
from the public water systern by an air gap or an appropriate backflow prevention
assembly in accordance with Conunission regulations.
(Z} No cross-coruiection between the pubtic drinking water sugply and a private water f�'' p p
system exists.� Where an actual au gap is not maintained between the publia water
suppIy and private water supply, an approved reduced pressurc-zone hackflow
, prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certifed backflQw prevention device tes#er.
(3) I*10 connecrion exists which would allow the retum of water used for condensin� �y` p ❑
� cooling ar indus�ial processes back to the public water supply,
(4) Na pipe ar pipe fitting which contains more than 8A% lead exists tn pri�ate water � � p p
distribution facilities installed on or after 7uly I,1988. ,
(5) No solder or tlux w�ich contains more than 4.2°/a lead exists in private water �,/ � ❑ • ❑
dis�ibution facilities installed on or after 7uly 1,1988.
. .
Water sarvice shaIl not be provided or restnred to the private wa[er dislribution facilities until the above conditious are determined ta be
in comgliance. F
I certify that the fallowing materials will be used 'zn the installation of the private water distribution facilities Iticated at
r,/o Gl/EsYy,QVE� and that the inspector will validate compliance during the inspectian process:
Scrvice lines Lead ❑ Copper ❑ FVC ' (] Qther �[
Solder Lead ❑ J.ead Free �` Solvent W�ld Q Other ❑
��
I recognize that this document shall became a permanent record of the aforementioncd Fublir Water System and that I am legally
responsib��for the validity of the information I have provided.
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Signature of Lice d Plumber Regis�ation Number
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Type of Re�istration Date
I recognize that•this d�ctunent shall hecome a permanent record af the afarementioned Public Water System and that I am legally
respon ' le for the validity of the infoanation provided.
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Signature of I pector Registration Number
1_�� S / - s -���"
Type of Registration IIate
1A'hilt-Customefc Cupy Yellnw-CilYs Cnpy Pialc.latpccinfs Copy