2014_1210 st i� /y�Y
CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residential � Commercial O TNRCC ID#0570040
I � f �%�l,� , upon inspection of the private water distribvtion facilities located at
g�� ��/r•o°� , which is connected to the City of Coppell Water System, do hereby certify
that, to the best of my knowledge:
In Non- N/A
Compli e Compliance
(1) No direct connection between the public druilcing water supply and a potential . � O ❑
source of contamination exists. Potenrial sources of eontamination are isolated
from the public water system by an air gap or an apprapriace backflow prevention
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking watcr supply and a private water [Y ❑ �
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��
prevention 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 return of water used for condensing GY ❑ ❑
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 � ❑ ❑
distribution facilities installed on or after July 1, 1988.
(5) No solder oz flux which contains more than 0.2% lead exists in private water B� ❑ ❑
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 condirions are determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution facilities located at
g�� ���p� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead O Copper ❑—/ PVC f9' Other L� �/`
Solder Lead � Lead Free Id Solvent Weld � Other ❑
I recognize that ' ocument shall come a permanent record of the aforementioned Public Water System and that I am legally
responsib ' ity of formation I have provided.
,�-3��75
Sig re o ensed umber Registration Number
.��5� �� -/�^f y
Type of Regis�ation 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 validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customefs Copy Yellow-Ci�y's Copy Pink-Inspcctors Copy