2013_0730 C�TY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential B' Commercial O TNRCC ID#0570040
I '` � ,D� �J • �I/� �/Q��� , upon inspection of the private water distribution facilities located at
� 5 �. /''�a.D�L L , which is connected to the City of Coppell Water System, do hereby �'ertify
that,to the best of my knowledge:
In Non- N/A
Compli Compliance
(1) No d'uect connection between the public drinking water supply and a potential � ❑ p
� 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 regulations.
(2) No cross-connection between the public drinking 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 backflow
���;;, prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester. . �`
a`;.
(3) No connecrian exists which would allow the retum 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 �f p ❑
distriburion faciliries installed on or after July 1, 1988. �
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ❑
distriburion facilities instal�on or after July 1, 1988.
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Water service shall not be provided or restored to the private water distribution faciliries unril th"�,above conditions aze determin�d.ito be
in compliance. ,�,,,--�`' �� .�;
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I certify that the following materials will be used in the installation of the private water dis�iburion faciliries located at �'
����.�G,����L.. and that the inspector will validate compliance during the inspecrio�i-process:
."'� `_
Service lines Lead ❑ Copper ❑ PVC ❑ Other
—�/ � �'
ol er Lead ❑ Lead Free I�'� Solvent Weld ❑ Other ❑
� -
I recognize that this document shall become a permanent record of the aforementioned Pubiic Water System and that I am�kgally_�
responsi le for the validity of the information I have provided. �"
,�� �-� �3 w s P-s-,�.r'�-__
Sig re of Licensed Plumber Registration Number �
� l�Iu� �� �P/� m b���. `�i� ya �� �/3a//3 �=
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 n' Yellaw-Ciry's CoPY Pink-laspeaors CoPY