2014_0701 CITY OF COPPELL WATER UTILITIES
� CUSTOMER SERVICE�NSPECTIOn
Residential Commercial p
� / TNRCC ID#057A040
I � � � �
[ /J , upon inspection of the private water distribution facilities located at
��S �P/r/'Afi r Q/',��� C.Uufi
,which is connected to the City of Coppell Water System, do hereby certify
that, to the best of my knowledge:
In Non- N/A
(1) No direct connection between the public drinking �,ater supp]y and a potentia] Comp]ia ce: Compliance
source of contaniiiiation exists. Potential sources of contamination are isolated � �
from the public water system by an air gap or an appropriate backflow prevention ❑
assembIy in accordance with Commission regularions.
(2) No cross-connecrion between the public drinking water supply and a pr�vate water
system exists. Where an actual air gap is not maintained be t w e e n t h e p u b l i c wa ter � � �
s u p p I y a n d priva te water supply, an approved reduced pressure-zone backflow
prevenfion assembly is properly installed and a service agreemeni exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the return of water used for condensing �
cooling or indus�ial processes back to the public water supply. � ❑
�
(4) No pipe or pipe fitting w1u�h contains more than 8.0% lead exists in private water �,/'
distribution facilities installed on or after July 1, 1988. '+� ❑ ❑
(5) No solder or flux which contains more than 0.2% lead exists in private water p� , ��
distribution facilities installed on or after July 1, 1988. � ❑
Water service shall not be provided or restored to the private water distribution facilides until the above conditions are dete
in compliance.
mvned to be
I certify that the following materials will be used in the instailation of the private water distribution facilitie
.S�S �Pr���4 ���C �s��_ s located at �
and that the inspector will validaTe compliaace dtuing the inspecrion process:
Servi��eS Lead ❑ �
Solder Copper ❑ PVC
Lead ❑ Lead Free ❑ Other p .
Solvent Weld � Other ❑
I recognize docume shall become a permaneat record of the aforementioned Public Water System and that I am le al
responsi f validi f the information I have provided.
g ly
Si re o ice Plumber � - ��-3�07 Z� .
Registration Number
Type of Registration �'l� ,D/�
Date
T recognize that this document shall become a permanent record of the aforemenrioned Public Water System and that I am le all
responsible for the validity of the information provided.
g Y
Signature ofInspector
Registration Number
Type of Registration
Date
��«-Custorpers Copy .
Vellow-Cirys Copy
Pink-lospeclors Cupy