2015_1114 CITY OF COPPELL WAT�ii UTXLITIES
CUSTOMER SERYICE fI�SPECT101�
Residential [�^ Commercial ❑ TNRCC ID#Q574040
f�
Z '` `� " � �r� •��`� u an ins ecti�n af the riti t
r p p �a t water disti-iLution facili�ies lncated ai
�-�� R��P—P wkiich is connecied tn the City of CappeII Water Systein,do hEreby certify
that,to the best of my l�oowiedge:
Tn Non- N!A
Compliance Complian�e
(i} No d'uecf connectian between the publia drisilcing water supply and a potential �f • Q p
sotsrce of cantamivatifln exYsrs. Potenbal sourcas af oantaminati�n are isolated ' '
fram the public water system by an air gap or an apgropriate baekflow preveati.on
assembly in accordance with Commission reguIations.
(Z} No crnss-connection b�tweea the pu�ilic drinlc�ig water suppiy and a privais water i� p �
system exists.��z1I�s�re an actu3.1 air gap is aflt maintainefl hetween tha pub]ic water
snpply and grivate water supply, an apprflved raducrd pressure-zone backflow� �
, preventiou asscmbly is properly znstafled and a ssrvice agreement cxists for
annual inspectiorisnd tasting by a certi�ed back#7uzv prevention device tester:
(3) A10 connecdan e�tisis which would aIIow the reiurn af water used£ar condensing �/ I� D
; cooliag ar�dustrial processas back to the public�vater suppiy,
{4) Na pipc orpipe fittzng which aontains more than 8.,Q%Iead exisis ui privzte water �- p 0
distribuRan facilitics instaIled on ar after 7uly I,I988.
{5) No salder or flux �y}k1C�1 COA�12ri5 3�,DCC t�1A. 4.2°/a lead exists in privatc water g,/ �p • �
dish�'butinn facilities installed on or a#�er July 1,I988,
�,. .
Water service shall aot be pravided or restored to the private water disizihufian fac�iries until the above canditiotts are detennined to be
in complian�ca.
I c�rtify thaC the follu •ing materials will be used in tize insEaliatian of t]�e grivate v�ater distn'butzan facilities I�cated at
�/�S P _aud that the inspec#or wvila validate complaance dursng the inspecrion process:
Service tines Lead ❑ Copger ❑ PVC ' ❑ Oflier
Solder Lead ❑ I.ead Free �` Solvent Weld O Other p
�•
I recognize that this document shall becoma a permaneni recard of the aforamentioned Pvbiic Water System and tl�t I am Iegally
r�spansib for the validity of the inE'ormation i Iaave provided.
,r �. �[U
Signature af Lice d Plumbez� Registtration.Num,ber
�-�l��.,� ._
Type of Registratiion Date
I secoguize thaGthis document shaIi become a pertnanent record af the aforementioned.PUblic Watcr System aad that T am IegalIy
respan ' le for the validity af the information pravided.
• ���
Signature of T pector Registzation Number
�� � �/ �� Lf r ��
Type af Regish-ation Date
X'Li¢.Customor's Cupy Ynllow-Citys Capy Piok•IasPeaafs C�pY