2015_1021 CITY QF COPPELL WATER UTILITIES
CiJSTOMER SERVICE fNSPECTI�P�
Residential [�3" Commercial ❑ TNRCC ID#U57fl04Q
f�
I r i `��� � " ' `"r� ,•��i`� u on ins ectian Qf the rivate wa[e '
Q �D f � � r dutr�Luh�u facilitizs located at
���Ln�n�� �wkiieh is connecied tn the City oi'Cappell Water System,do h�reby ceitify
that,!o the best of my knowledge;
� Non- N!A
CompIiancs Campliance
{1) No d'uect connectiun between Yhe publio drinking water supply and a patencial � � Q p
source of contamiBati.o❑ exists. Potent�al sources af cantamination are isolated ' '
from the public water system hy an air gap or an apgrogriate baekflow preuerrti.on
assembly in accordance with Couunission regnlat�ans.
(Z} No cr�ss-connectian b�tween the public drinlcing watcr supply aud a privais�vater C�' p 0
system exisu,�1Yhera an actual au gap is not maintained between the pubIic water
sr�ppIy and grivate water svpply, su apprflved rec�uced pxessure-zone �rackflow �
, prevention assembly is praperiy instalisd and a service agzeement exists for
annual in:spectionand testing by a certifed hackflavy prevention device tester,
(3) No connecrian exisis which wou3d a�]ow the rctvrn of watsr used for condensing � ❑ D
} cooIing or indus�zal processes back to the public�vater suppiy,
(4) Na pipe arpip�fittzng which contains more than 8,D°�o lead exisis iu private watez �� CI ❑
dis�ibntian facil�tics insialled on or aft�r.Jufy I, 198$. ,
(5) No solder oc fiux w3.uch cauf�ins more thau 4,2% lead ex.ists in pri�ate waler � �[] • p
distri'bntion faczlities instaTjed on or after July I,1998.
,,. .
Water service shall not be pz�pvided or restored to the private water dist2ibuiian facilzdes until the above eonciiti.ons are deterzizznad to be
iu caznpliance.
I certify tIlaC tbe falIau-ing materials wi1]be used in the installaEian of the grivate urater d�stn'bution facilities l�cated at
and that the inspector wiia validate�ompliance drning the inspection process:
�erva�,�ee liztes Lead O Copper Ll PVC ' C� Qtlier
Solder T.ead L] I.ead Frea �` Soivent Weld Cf Ofher Q
a•
I recognize that this docnment shail become a pez'manenf record of the aforemcationed Publi�Water System and tl�at I am Iegally
z�spQnszb for the validity of the information I hava provided.
,I � �VJ
Signattue af Lice d Plumher Registration.NumbeF
�.�P,� /fd�?/ ��i�5"
Typa of RegistrarioQ Date
X.recognize that�this documeni shall become a pennanent record of the afarementianed Public Water System and thai I am IegalIy
r�spon ' le for tize validity af the infarcnation pravid�d.
� ��,�j
Signature o�'I pector Re�istration Number
��'� � �r �'�
Typc ofRegtsttation Date
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