614 Westhaven CITY OF COpPLLI.WAT�R UTILITIES
CUSTOMER SERYICE�NSPECTIOlti
Residentiai [�" Commereia! ❑ TPIRCC ID#05743040
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I �`��"" � " ` ~'`� ���`� upan inspectiQn af the prn�ate water distribniion facilitiss lncated a
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� �"�+Sf h sf�.� ' ,which is connecied to the Ciry oi'Coppell Water System,do hereby certify
that,to the bcst of my knowled�e:
In Non- NIA
�nmpliance Compliance
(lj No dxzect cauiaection bet�veen the public drinlcing wazer supply and a potentiai �f ' Q p
source of contaminatioa exisu. Pofent�al svttzc�s af coutuminatinn are isolated ' '
fram the public water system by au air gap or an apgmpriate backtivw preveestion
assemhfy in accordance with�amtrcission regula�ans.
(2} No cr�ss-connectian betweea the pubIic drirk,n_o water suppiy azid a privaie water Ct�✓ p p
system exists,�ti�fsere an actuaI air gap is not maintained betvr$ea the pubSic watcr
suppIy and privaTe v�ater sv,pply, an appro�ved reduced pressurc-zqme b�ckflow �
, preventian assembly is properly installed and a s�rvice agreement exists for
annual iuspeetionand testing by a certif ed hack#l4w prevention device tester:
(3) No cnnnectian exists tyhich would aIlaw the return of water used for cnndeusing �/ p D
� cooImg or iadus�i.al processas back ta the public water st�pply,
(4) Na pipe orpipe fitting vv�,ich contaizis more[han 8,0%lead exisfs in private watez � - p 0
dis�ibuaon faciIities installed on or after duly I, 1988. .
(5) Na salder or filux �v3�ich eoniains more tfian 4.2°/a lead exists in private �vater g,/ �❑ � p
cEish��ution facilitirs instal]ed on orafter July 1,I938.
�. •
Water service shaIl not he provided or restored Ya the private water distxibution fac�iries un[il the above eandetions are detennined ta be
in compliance.
I ceztify that tUe�a114�-ing materials wiIi be used ia tile insfallatian of the.g.rivate water d�sm�but�on facilities Ibcated at
�C/ uC�t�2�ie•,� aud that the inspector wiIl validate�oFnpliance d�ug the inspecrian process:
Servrce[iFees Lead O Copper � PVC ' � Otlier �
Solder T.ead � I.ead Fre� �' Solvent Weld Cf Other ❑
a�
T recoo;,e that this document shall become a permaneni recard of the aforementioned Publir Water System and that I am Iegally
responsib for the vaIidity of the information I have provided. �
, �, �j G
Si�ature af T,ice d Plumber Registtration�NumSer
�.�P� y/�� J z�,�
Ty}se of Re�isirarion Bat�
1'recogztize tliat•this document shalI beoome a pecmanent record of the aFflremeurioned.PabLie Watez System aud tlsat I azn legalIy
respon ' le far tfie validity af the infarmabon provided.
��.�
Signature o�'I pector Re�istration N�tmber
��'� S --fLf
Tyge oFRegis�-ation �..._ ,__ Date
S5'hiu-Cns�amcrs Cupy YallOw-Cit�s Copy pinlc.[piptdofs Cnpy