2016_0211 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCCID#0570040
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I ���~ � i�!'t �c �~-��� , upon inspection of the private water distribution facilities located at
�,�� J� C�Q�p,�•-��� K� , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge: "
In Non- N/A
' Complia e Compliance
(1) No direct connection between the public drinking water supply and a potential � ❑ ❑
source of contaminarion exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water � ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflow�
prevenrion assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing �� ❑ p
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water p� ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water pr ❑ ❑ �
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities uncil the above conditions are detemuned to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution faciliries located at
__ /,� � �- �� .�-� J� oC �, and that the inspector will validate compliance during the inspecrion process:
�
Service lines Lead ❑ Copper ❑ PVC ❑ Other B' r
So der Lead O Lead Free � Solvent Weld ❑ Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validiry of the information I have provided.
�' ���_ <�z 7 3
' /a�ture of Licensed Plumber Registration Number
I �. ,'""� �1� I�t.s'.Sd 1 '-� U �/'/l /fO
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res�onsible for t�yalidiry of the information provided.
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'� :,�.�� r11- 1;� 7 � �y�f S �.�
,� ' nature of Inspector Registration Number
. �����1 �' � o;� r ��
Type of Registration Date
White-Customefs Copy Yellow-Ciry's Copy Pink•laspectors Copy