2014_1029 CITY OF COPPELL WATER UTILITIES
_.�,: �CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCC ID#0570040
I �`�(•l�rG�'�'" ,upon inspection of the pm�ate water distribution facilities located at
�� �ry�G✓G�n , which is connected to the City of Coppell Water System, da hereby certify
that,ta the best of my knowledge:
In Non- N/A
Com1pli�e Comgliance
(1) No direct connection between the public drinking water supply and a potential L9' ❑ ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regularions. �
(2) No cross-connection between the public drinking water supply and a private water Lzl ❑ ❑
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 I.� ' ❑ ❑
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 CY� ❑ ❑
distribution faciliries installed on or after July 1, 1988.
- (5) N�,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 until the above condirions are detemuned to be
in compliance.
I certify that the following materials will be used in the installation of the private water distriburion faciliries located at
��� �Gt�'Vl C v2vt and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead O Lead Free �B� Solvent Weld ❑ Other ❑
,
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res nsible for the validity of the information I have provided.
/,r ` l���
nature of Licensed Plur'tiber Registration Number
w s '�s r� � 2 �j ' ��
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
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customers Copy Yellow-Ciry's Copy Pinlc-Inspectors Copy