2013_0917 ����,d�e
CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCC ID#0570040
I .✓V 1-� N�� � I �s'�°`- , upon inspection of the private water dis�-ibution facilities located at
l,° hich 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 direct connection between the public drinking water supply and a potenrial '� ❑ ❑
source of contamination exisu. 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 � ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
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 retum of water used for condensing `� ❑ ❑
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 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 � ❑ ❑
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 wil be used in the installarion of the private water dis�iburion facilities located at � O
� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �pek
Solder Lead ❑ Lead Free ❑ Solvent Weld ❑ Other '6�
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
re p nsible for the validity of the inf atio have provided.
�� � UCO O � /
Sig ature of Licensed Plumber Registration Numbee
' q - IZ— l 3
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
r s nsible for the validity of the inf ation rovided.
� 3�34
Sig re of Inspector Registration Number
� � -- � `7 � � 3
Type of egistration Da�—
WMite-Customers Copy Yellow-City's Copy Pink-Inspectors Copy