2015_1020 CITY i)F COPPELL WATEIt UTIL�TIES
C�7STOMER SERVICE fI�SPECTIOI�:
Residential [�" Commercial ❑ TNRCC IIl#0574040
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I l i `��� �MY�' ���`� npon inspectinn af the private water distribution facili�i�s lncated at
_ /��.� �e..,�Cr��r wluckt is connecied to the City oi`Cappell Wzter 5ystem,do hercby certify
that,to the tsest of my knawledge:
Tn Non- AtIA
Camplianc$ Campliance
(1) Na d'uect counectian between tha publie drinking water supply and a potential �/ ' Q ❑
source of cnntami�ation eacists. Patential satuc�s of contamination are iso]ated � '
from the prtbiic v,�ater system by an air gap or an apgropriate backflow pzeveatioR
assemb3y in accordance with Co�aunission regnla�ans.
(2} No crass-connectiaa between the gablic drink.zzig water suppLy aud a privaze water f� � ❑
system exists,�l�7here an ackv.il air gap is nfltmaintained hetvreen the pubIic.water
supply and private water supgly, an approved rarluced pressure-zone backf�o�� �
, prevention assembly is propariy instalied and a ssrvice agreement exists for
annual inspectiorLand testing by a ceriifed back#lozv prevention device tester;
(3) No connection exists zvhic�wau3d aIIow the retum af water used fas enndensing � ❑ �
i cnoF�g or indus�ial processes baolc to the pnblic water supply,
�4) Na pipe arpipe�itring which contaix�s mare rhan 8,Q%�ea�l exists in grivate water � - p p
disizibntian faciIitzes instaIled on or aft�r.duly I, 1988. .
(�) No solder nr fiux which contains more than 0.2°/, lead exi.sis in pri�ate water �/ �❑ ` p
dishx'buCion facilities insta�led an ar after July I,1938.
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Water service shall nat be pro�videc3 or restored ta the privafe water distribu[ian facilities unti,l the above eanditi.oas are determ.ined to be
iu compliance. ,
I certify that t]�e fal]owi.n materials wiI]be used in the insEallaEian af the grivate�uatez disn-i"bution faciIities i�cated at
6 S 7-i,�lf�� aad that the inspector will validate complianee during the inspecrian process:
Service lifles Lead O Coppe� L] PVC - p Qther �
Svfder Lead ❑ S�ead Frea �' Solvent Weld O Other ❑
r,•
I recne"e that this doc�ment shail become a pezmanent rec�rd of the aforemeatSoned Publi�Water System and that I am legally
r�sponsb fnr the valirlity of the infotmation I have provided. ��
, �
Signature af Lice d Plumber Registratio �Num eF
�sP� fo�Zo��S
Tyge of Regisirario¢ Date
I recoguize that•this d�cument shall become a permanent record of tfie aforementiQned Publi�Water 5ystem and that I am IegalIy
respon ' le for the validity af tlie mfacmatian pravided.
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Signature D�Z pector Registratinn Number
��v� S �f�-�
Ty�e ofRegishation Date
VJbitc-Cus[amc�c CuDY Vaklow-Cit�?s Cupy Piolc-Icsp�qafs Cnpy