627 Westhaven �ITY QF COPYELL WATER UTILIT�ES
C�JSTQMER SERVIC��NSPECTIOIti
Residential �,�`' Cummerciat ❑ TNRCC ID#057D04D
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I ���`�" ��� f �^''`� ,u n ins ectinn of th� rivate wate
/ -7 ! F� P F r distnbution facilmss located at
__ (�� / �./���/��'4'de ,which is cotmecied ta the City of Coppell Watcr System, do hercby certify
that,ro the best of my knawledge:
� PTon- N/A
Compliance Compliance
(i} 3Vo direct con�aectiaz�between the puhlic drinfcing water supply and a potential �` ' ❑ p
source of contamination exists. Potential sonrces of cantumination are isolated ' '
from the public water system by an air gap br an appropriate backflow prevention
assembly in accordance with Commission regulations. �
(2) No cruss-connection betw�en the pubiic drin}eing water supply and a private water IY D O
system exists.� 1�Vhere an actual air gap is noi rnaintained between the public water
suppIy und private water supply, an apprnved rednced pressurc-aons backflot�� �
, preventiou assembly is prnperly installed and a service agreement exists for
annual inspection and tesfing by a certif ed backflnw prevention device tester.
(3) IVo connecrian exists which would allow lhe retum of water used for condensin� � � �
� �aoling or industria}processes back tv the public water supply.
(4) Na pipe or pipe fitting which contains mure than 8.0% lsad exisis in private water � � ❑ p
distri�urian facilities instaAed on or after,Tuly I, 1988. ,
(5) No solder or fiux which contains mare than 0.2°la lead exists in private water t�/ � p • p
distribution facilities installed on ar after July 1, 1988.
Y•' �
Water service shaIl nflt be provided or rest�red to the private water distribution facilities uatil the above eonditi.ous are detezmi��ed tq be
in coinpliance.
I certify that the fallowing materials will be used in the installation af the.private water distriburion facilicies ldcated at
and that tha inspector will validate compliance t�uring the inspection process:
.
Servace lines Lead ❑ Cogper ❑ PVC � CJ Qttier �[
Solder Lead q X.ead Free � Solvent W�ld O Other ❑
��
I recognize that this document shaIl6ecome a pernianent re�ord of khe aforementianed Puhlic Water System and that I am legally
responsib for the validity of the informution I have provided.
�7" �"'
Signature af Lice��l Plumber Re isirati n�Number
��.��'. -
Type of R.egistrafion D te
I recognize that�this document shall become a pezznanent record of the aforementioned Public Water System and that I am legally
respo ' le far t�ae validity af the infom�cation provided.
C �-'�,
Signature of I ector Re is tio Number
6� � � -
Typs af Registration Date
Whiu•Custamer'c Cupy YeClow-Cilys Copy Pidc.Insponofs Copy