2014_0821 CITY t9��CC?P��LL WATLit LITILITIES
��J�'I'�ll�fElZ SERY��E�!'�SPECTICl1�
Rc.�idential �'`"' Camrn�rc�at G{ 'CNRCC'T�#�5704�U
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�_��-s�� ��`�� � :'�'�'� ,upon insp�ctic�n+�f t�ae prir�ate �raxer distributiota�`aciliti�s lacated at
_�,?� CE�-r--t+E�r�►�e"� �, whach is cnnnectefl to the City o�Coppell W�t�r Sy�tem,da hercbvi certifp
tt►�t,ta khe best of�y knowledg�:
tn �on- t�If.�
�ompliance Caa�plia�a�e
�t j hTr� direct co�nectio�r betwc�� the gubtic drinking watcr supply a�sd a potential �` �I t�
sc�urc� af cfant�nxir�ation cxists. Patenta�� sa�rces caf contamiz��tinn art ist�l�t�c1 ,
f��x�a tF�e public v�rat�r system by an air gap ar an apgrog�rigt�backi3nw�ar�v,entiean
assembly i�a�cc�rdance wit}�C�n�ssi�n reg�alations.
(2� No erass-conn�ctiou between'th�public drinkirig wat�r supply and�priv�te w�ter �'' f� G,I
syste�n exisrs.�Wherc an actuat su g�p is not rr�ain�ined beto�r�en thc public w$#ec
supply and privat� wat�r supplY, an approve�l r�duc�d pre�sure���rne b�ekflouR
. prevention assembly is pc�perly �as��lled and a s�rvice agreemenk exi�ts for
a�nnua�ia�spectis�and testin�by a ccrkii`i��i backflpw preves�tion davics test�r.
��) i�'a cannection e�ists whi�h wauld ail�vv the retum ot�+v�k�r us�ci fi�r conderasing � L� �3
, cc�oSin�or indusarial pro�ess�s back co thc�u�al��urater suppty.
(4) Na pipc or gipe�tting which conta€ns�t�re than$.0°fo lead�xists iaa privat+e waiex � I� C�
distribuk�o�fa�ilit��s unstalI�d�n c�r aft�r Iuly 1, t98$.
�rj N� srrlder ar flux wl�ie�a c�s�tains mor+e tihan {�.2°,� tead exists in g�iv�Ee wa,ter � ° � ` 1:�
diatn`bu�tio�t faeilities i�tstatled�t�acu��fEerTu1�1, 19'�f3. �
w. '
Water service shnIl not be pruvided or restased ta the privste water distribution faciliti�s unril ths�bave c�nditions are detem7in��tc�b�
�iaz compls�ncc:. � , � ��
I c��tiCy that the fr�llowing rnaterials witl be us�ed in t�rc installatian�f the�arivat�watex disuibution facilitics Icscated at
��Z. �-�-•�--te�—I��s�ry �nd tltat tlte iszspector will v�la'date�c��tplia�ce d�ring t��inspectian pra�cess:
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de Lcad CJ L�sd T�'r�e � �z�luer�t'Weld � �ther �
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I reccs�;ni�e that this d�eument sha11 becr�me a p�n�rancnt recc��d+af#3��afrrr�rnention�d I'ubtic Water Systcm�nd that I am le�ally
r�sp�nsib�f�r th�valScii�r c�f�tf�c ir3f'ormation I hav+��pr��aidet�.
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Sti���ture of Lic� d Pl� R��isti��tion�l`+�umtr�r �
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"I Kvp�of 38egistration I�dt�
�recn�nize tt�ar•tk�is document sha11 become a pem�anent reaord of the�faremenci�n��3 Pubiic W�tcr System and th�t T am le�ally
rss�son�.z�le for the valid,�r c�f rh�infor�a�o�pravided.
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