631 Westhaven CITY OF CQPFELL WATER UTILITIES
�USTOMER SERVICE�'NSPECTIUI�
Residential � Commerciat ❑ TNRCC ID#0570040
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j /f `���- / ' f ✓r� f �'`/ ,ugon inspectian of the private water distri6u#ion facilities ]ocated at
!0 3�11��l��l�CN ,which is connecied to the City of Coppell Water System, do hereby certify
: that,to the besk of my knowledge;
In Non- T'JlA
Compliance Compliance
(1) No direct connection between the publio drinking water supply and a potential �/ ' p ❑
saurce af contamirtation exists. Potential saurees af cantumination are iso]ated ' '
from the public water system by an air gap or an appropriatc backflow prevention
assembty in accordance with Commission regulations.
(Z) No cross-connection between th�put�{ic drinking water supgly and a privaIe water [� p p
system exists.� Where an actual aiz gap is not maintained between the public water
supply und private water supply, an approved reduced pressure-zpne backflow �
, prevention assembly is properly installed and a servicc agreement exists far
annual inspection and testing hy a certifed backflow prevention device tester.
(3) I�10 connection exists which would allow the return of water used for condeasin� �y' p ❑
� cooling ot'indus�ial processes back to the public�vater supply,
{4) No pige or pipe fitting wh�ch cantains more than 8.0°�0 lead exists in private water � � O O
distribution facilities installed on or after duly 1, 1988. ,
(5) No solder or fiux which contains more than 0.2°la lead exists in private water �/ •❑ � ❑
distribution facilities installed an or after]uly 1, 1988.
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Water service shaIl nnt be provided or restnred to the private water distribution facilities until the above eondiri.ons are dCtermi�ed to be
in complianee. ,
I certify that the fallawing materials will be used in the installation of fhe priva[e water distribution facilities ItScated at
and that the inspector will validate comptianee during the inspection process:
,
Service lines Lead ❑ Copper ❑ PVC ' ❑ Qther �i[
Solder Lead Ct J�ad Free J�` Solvent Weld ❑ Other ❑
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I recognize that this dn�ument shall becvme a permaneni recard of the aforementioned Fuhlic Water System and that I am legally
responsib for the validity of the informution I have provided.
,,,�� �, � ��
Signature flf Lice d Plumber Registrati' n NumheF
k;,��s�� �
Type of Registration D te
I recoguize that�this document sha11 became a pem�anent record of the aCorementioned Public Water System and that I am legally
respon ' ie for the validity af the infoczriation provided.
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Signatur��i�ector Regis atio Number
Type of Registration Daie
N'hilt-Customef t Cupy Yellow-Citys Cnpy Pink-laspcnafr Copy