2014_1029 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERYICE INSPECTION
Residential 'H Commercial 0 TNRCC ID#0570040
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I � ; l� �� ,upon inspection of the private water distriburion faciliries located at
� ��r►i , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Complian Compliance
(1) No direct connection between the public drinking water supply and a potential � ❑ p
source of contaminarion exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion` `'
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water G7�'�'� ❑ ❑
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
prevention assembly is properly installed and a service agreement exists for
annual inspecrion and testing by a certified backflow prevenrion device tester.
(3) No connecrion exists which would allow the return 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 [].�"''` ❑ ❑
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 � ❑ ❑
distnburion 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
in compliance.
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I certify that the following materials will be used in the installarion of the private water disuibution facilities located at
�� �� G��`��v'�va� and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper 0 PVC ❑ Other �
Solder Lead ❑ Lead Free C�'""�r� Solvent Weld ❑ Other ❑
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 validity of the information I have provided.
_
ro. �� �� ��
nature of Licensed Plumber Registration Number
� � '�� �/� ' � f� ' /"�
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•Customn's CoPY Yellow-City's CoPY Pinlc-Iaspeaors CopY