2016_0226 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOr
Residential � Commercial O TNRCC ID#0570040
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, upon inspection of the private water distribution facilities located at
�-,,_1 G.`���,R , which is connected to the City of Coppell Water System, do hereby certify
that, to the best of my knowledge:
In Non- N/A
Compliance Compliance
(1) No d'uect connecrion between the public drinking water supply and a potential 0''� O ❑
source of contamination exists. Potenrial 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 G�' ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflo��
prevenrion assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connection exists which would allow the return of water used for condensing GY' ❑ ❑
cooling or indus�ial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0% lead exists in private water C,]�.- 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 [y p ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities unril the above conditions are determined to be
,in compliance.
I certify that the following materials will be used in the installarion of the private water dis�ibution facilities located at
`"�'� � GL.C�. and that the inspector will validate compliance during the inspecrion process:
;
Service lines Lead ❑ Copper ❑ PVC � Other ❑
er Lead 0 Lead Free � Solvent Weld ❑ Other O
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the alidi o/f,the information I have provided.
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Signatur�of Licensed Plumber Registration Number
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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
responsible for the v idity o the ' formation provided.
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Si ture of Inspector Registration Number
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Type of Registration Date
White•Customers Copy Yellow-Ciry's Copy Pink-fnspeaors Copy