2015_0128 CITY OF COPPELL WATER UTILITIES
� CUSTOMER SERYICE INSPECTIOT
Residential P3�f , Commercial ❑ TNRCC ID#0570040
I��i�l� �Gl[� 2'f � ,upon inspection of the private water distribution facilities located at
/�'/ �C!vYl� /� D�? �-f' , which is connected to the Ciry 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 drinkin$ water supply and a potential � ❑ p
source of contaminarion exists. Potenrial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regularions.
(2) No cross-cQnnection between the public drinking water supply and a private water C7 O ❑
system exists. Where an actuat 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 return of water used for condensing C�l ❑ ❑'
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0°/a lead exists in private water p' ❑ ❑
distribution faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water C'l ❑ ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private`water distribution facilities until the above conditions aze determined to be ,
4
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion facilities located at
'��7 c 4/�►��¢t 0� �'� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper O PVC O Other �
ol er Lead ❑ LeadFree � 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.
_ �l- �J'�73 l�.�'.S-f�
' nature of Licensed P umber Registration Number
�f��►� ����,�� � I'r��' �/ —�� �:s''
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
resp nsible for the validiry of the information provided.
/�'l- �� � 3
' nature of Inspector Registration Number
�'m �° ws Ps -��- o� - � -�s -
Type of Registration Date
White-Customers Copy Yellow-Ciry's Copy Pink-laspeaors Copy