2014_0116 ;�:_ _
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�*� , C�TY OF COPPEY�L WATER UTILITIES
� ''e �`" CUSTOMER SERYICE INSPECTIOI�
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� ��� � Resi.dential Commercial '. O TNRCC ID�p 570040
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I ���y ��v�'A`��� , u on'in` ection of the nvate water dis�ibution facilities located
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' ` " '�onnected to the City of Coppell Water System, do hereby certify
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that,to the best of my know e ge: `� ����a ��� `, ,
.a � �L\�N��\� �
_ �'�t� c� `� In Non- N/A
��` Compliance Compliance /
(1) No direct connection between the pub�ic drinking water supply and a potential � ❑ p�
source of cbntamination 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 dri�king water supply and a private water ❑ ❑ �
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
prevenrion assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connection exists which would allow the ret'�m of water used for condensing U ❑ ❑
cooling or industrial processes back to the public water supply. �
(4) No pipe or pipe fitting wluch contains more than 8.0%lead exists in private water L'J ❑ ❑,ry�
distribution facilities inst�lled on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water C� ❑ ❑
distriburion facilities installed on or�fter July 1, 1988. i �,
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Water service shall not be provided or restored to the private wat�r`distribution facilities until the above conditions are determined to be
in compliance.
I certify that the,foll w' �a�:il�.be used in the installation of the private water dis�ibution faciliries located at
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Service lines' Lead ❑ Copper O PVC ❑ Other C3�
Solder Lead ❑ Lead Free ❑ 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 validity of the infom►ation I have provided.
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Signature of Licensed Plumber Registration Number
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Type of Registration Date
I iecognize that this document shall become a peimanent record of the aforementioned Public Water System and that I am legally
responsible for the validiry of the information provided.
Signature of Inspector y Registration Number -
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,„� Type of Registration Date
While-Customers Copy Yellow-Ciry's Copy Pink-►ospeaors Copy