2015_0327 " CITX OF COPPELL WATER UTILITIES
- CU,,STO}VIER�SERVIC�INSPECTIOr
".� ,
e '-�: Residential � Commercial 0 TNRCC ID#0570040
I ,upon inspection of the private water distribution facilities located at
CG1 � I'�Of7 �� , 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 d'uect connection between the public drin,king water supply and a potential 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 Lf ❑ ❑
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 inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing 18' ❑ ❑
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains rnore 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 � ❑ ❑
distribution 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 installation of the private water dis�iburion faciliries located at
''�G 7 �ie�,-.r��Q DY� ^ and that the inspector wi11 validate compliance duriag the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other ❑
Solder Lead ❑ Lead Free ❑ Solvent Weld ❑ O�her ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsib�r the validity of th�e,jpfoFination I have provided.
/�l- y2 � 3
gnature of I,icensed Plumber Registration Number
tQ J'�? � GrJ S p .� D 3i�� 7/�s
Type of Registration Dat—�
I recognize that this document shall become a peimanent record of the aforementioned Public Water System and that I am legally
resp nsible for e validity of the information provided.
_ �� _�z � 3
' ature of Inspector Registration Number
�� � Gt/S7�.S �3I� 7`�.5�
Type of Re stration Date
White-Customers Copy Ycll�'w•City's Copy Pinlc-Inspenors Copy