2015_1014 CITY OB COPPELL WAT�R UTTLITLES
CiISTOMER SERiTICE�NSPECTIOP:
Residential [�Y' Commerei:�I ❑ 'TNRCC IA#057(i040
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I 1 i `��'� / '' r'`U ' ���`� upon imspectiQn af ihe grivate water distri6raiioa facilitias locaced at
�`l� ���E!��5 �wkuckz is connecied to the C'sty ot Coppell Water 5ystem,do hereby certify
that,Eo tl�e best of my knawledge:
�n Non- NIA
�nmplian�e �ampliance
(17 No d'uect consxectiou betuseen the publia drinkiug water supply and a potentrai �1/ ' p ❑
source of contamivation exists. Pofential soure�s of c�ntamination are isolated ' '
fram the public water sys#em by an air gap or an aggropriate backflow preveatian
assembly in accordance with Cou�.tnission regula�ans,
(2) No cr�ss-coz�necu�a b�twsaa the gubIic drinking zvazcr suppIy aud a privais-�rater C�" p p
system exists,�ti�Ther$an actu�I au gap is notmaintained hetwecn the publia water
suppIy and pzivaTa water supgly, an approved reduced pressure-zone backf�ow� �
, pxeventian assembly is proparly instalied and a ssrvice agreement exisis for
annuai inspectio�and testiug by a cerfif ed back#laiv prevention device tester.
(3} No connectian e3cisis whicl�would aIIow the return:of'water used for enndensing � ❑ �
} cooling ar indns�zal processas back Yu the pub].ic water suppiy,
�4) No pipe arpig�fittiug which contains m�re rhan 8,0%�ead exists in private watez �- p p
dis�ibutian facilitics insraIled on ar af(�z.duIy I, 1988. ,
(5) No salde� ar flux tivbich contaizts mora than. 4.2% lead exis�s in pzi�atc vtrater �,/ �p � ❑
dish�'bution facilities instailed on or af�er July 1,1988,
.. .
Water sesvice shaTl not be provided oz restored to the privafe water distsibuLian facilaries until the above eanditi.otts ara detenm.ined to be
in compliance. ,
I cetlify that tUe fu11o�-ing materials wiTl be used in the installati�n of t]�e.gzivace urater dism�burion facilities Idcated at
�`���r�5 aad that the inspector�svil�vaxidale compliance duiing the inspecrian proeess:
Service li�tes Lead � Copgec 0 PVC • ❑ pther �
SvIder T.ead ❑ I.ead Frea �' Snlveut Weld O Ofher Q
�•
T recoo;'e that this documant shall become a permaneni recard of tl�e a;forcmentianed Puhli�Water System and that I am legally
responsb for the validity of the information T have provided. ��
, �
Signature nf Lice d Plumber Registration�NumbeF
�}�P� , .._
Type of Registrarion Date
I recoguize that•ihis d�cumcnt shalI become a permanent record of tlite aForementiQned Public Water 3ystem and that I am legally
respan � le far tlie validity of the information grovided.
���
Signacure of T pectar Registration Number
��`''� � �U �r `"�- �s
Type of Regish-ation � ��te
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