2013_0826 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
T�Residential GY Commercial ❑ ID#0570040
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I r � '- x' ''`� '�` � ,upon inspection of th�private water distribution facilities located at
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j / ;1�c.r�JC � "� , which is connected to the City of Coppell Water Syst,�m, do hereby certify
that,to the best of my knowledge:
In �1bn- N/A
Compl� ce �Compliance
(1) No d'uect connection between the public drinking water supply and a potential � ❑ ❑
source of contamination exists. Potenrial sources of contaminarion are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
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 backflo��
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) �To connection exists which would allow the return of water used for condensing � ❑ � �� ❑
�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 [� p ❑
distribution facilities installed on or after July 1, 1988.
(�) No solder or flux which contains more than 0.2% lead exists in private water L�' ❑ ❑
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 detemiined to be
in compliance.
I certify that the followin�materials will be used in the installation of the private water distriburion facilities located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead 0 Copper ❑ PVC ❑ - Other L7'�� ;J�`
Sol er Lead ❑ Lead Free O Solvent Weld ❑ Other ❑
I recognize that this document shall ome a permanent record of the aforementioned Public Water System and that I am legally
respons� r the alidity o fo tion I have provided.
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Signature of License lumber Registration Number
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Type of Registrat�n Date
I recognize that this document 1 become a permanent record of the aforementioned Public Water System and that I am legally
respo ' e for the vali ' e information provided.
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Signatufr.�o Ins�ctor Registration Number
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Type of Registration Date
White-CustomeYs Copy Yellow-Ciry's Copy Pink-faspeaors Copy
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