2013_0321 . �- ._.
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- CITY OF COPPELL W�►TER UTILITIE�
CUSTOMER SERVICE INSFECTIOI�
Residential �"' Commercial 1] ���ID#057Q040
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I _ _.:�a�t �!. .�+.�r;rr. ���J" ,upon inspection of the private water distriburion facilities located at
1"';� 5. tr'��fLL.... ,which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- .;" N/A
Compliance Compliance
(1) No d�irect connection between the public drinking water supply and a�potential �"' ❑ ❑
source of contaminarion exists: Potential sourc�s of contamiination are isolated
from the public water system by an air gap or an appraprist�backflow preven�i�n
assembly in accordxnce with"Commission regnlarions.
(2) No cross-connection between the public drinking water supply and a private wat�r: p� p ❑
"` system e�tists. Where an actual airgap is not.maintained between the public water
�� supply and private water supply, an approved reduced pressure-zone backflov��
,
p��vention assembly is praperly installed and a service agreement exists for
' annual inspecrion and testing by a certified backflow prevention device tester. ;
vy
(3) , No conriecrion exists which would allow the retuta of water used for condensing C� ❑ ❑
� cooling or industrial processes back to the public water supply.
(4)3� No pipe or pipe fitting which contains more than 8.0%lead exists in private water C� ❑ ❑
distribution faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water L�""" '� ❑ ❑
- distribt�tion facilities i�stall�d Qn or after Jul�..l, 1988. ` ,, � . '
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W�ter service shall not be provided or restored to the private water distriburion faciliries until the.above condirions are detCrmined.to b�: . �
in compliance. , .
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I certify that the following materials will be used in the installarion of the private water dis�iburion facilities located at'
��7' S'. C""'�,�:�E�.(� �'d7t�'LL.,� '7� and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper O PVC ❑ Other L� :�
- 1 er Lead ❑ Lead Free G�'' Solvent Weld ❑ Other 0
I recognize thai this document shall become a permanent record of the aforementioned Public Water System and that I ann legally
respo ible for the validiry of the information i have provided.
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' ature of Licensed Plumber Registration Numbef
�! ���r! ��'� �i�`rMr.�r�Y1w�r i�E �{.+���,.✓ a,r�'/ �f I.�JI�C'�./ l.P
Type of Registration Date `
I recognize that thisdocument shall become a permanent.record of the aforementioned Public Water Sy�tem and that I am legally
responsible for the validity of the information provided.
Si$nature of Inspector Registration Number ''"
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Type of Registration Date ' ;,
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White-Customels CoPY _ Yelbw-City's Copy Pink-lespectors Copy
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