2014_0707 i
� CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
-T'C�C�
Residential � Commercial ❑ � ID#0570040
I �c.����� � �^' `a Y'��'� ,upon inspection of the private water distribution facilities located at
�f (�� (� •'r����'�� V,� ��`� `� ,which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
� `�� Compliance�,�.� Compliance
, , �,
(1) No d'uect connection between the public drinking water supply aI'nd a potential C� ❑ ❑
source of contaminarion exists. Potenrial sources of contaminatioA re isolated
from the public water system by an air gap or an ap�ropriate backfl6wJp evention
assembly in accordance with Commission regulatioi�s.
,,,,
(2) No cross-connection between the public drinking wa�ei supply and a pn�ate�water E7� ❑ ❑ ,
system exists. Where an actual air gap is not maintained between-th�public `water
supply and private water supply, an approved reduc�:d pressure:zone bac�ov��
prevenrion assembly is properly installed and a 's�r�ice agreement exists for,�r
annual inspection and testing by a certified backflow p�eventioi'��evice,tester. r,_`F �
_,�,�
(3) No connecrion exists which would allow the retum of wa er use� for condensing ` ��'� E�� ❑ ❑
cooling or industrial processes back to the public water su�p�ly. �'"°° ' `
� ,� ���x rr�..
(4) No pipe or pipe fitting which contains more than 8.0%lea3�e�acist n pny�water �' ❑ ❑.
distriburion facilities installed on or after July 1, 1988. ' � �;� �`�, `', " r"
� � �. d � � .
�` ❑ ❑
(5) No solder or flux which contains more than 0.2% lead>-� ist��tn`pnvate;water � ,
distribution facilities installed on or after July 1, 1988 � '�� ;*
��� =.�, �
����.��:� �. � .��.� � � �
Water service shall not be provided or restored to the private water distrib�ti�on�aciliti«es until the above condirions are determined to'be
in compliance. �°'�.� � r"�,��
I certify that the following materials will be used in the installation of the private water distriburion faciliries located at ����
�•���P�� V q `�� � and that the inspector will validate compliance during the inspecrion process:
�_
n
Service lines Lead ❑ Copper ❑ PVC ❑ Other C�]/ 1 �
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
responsibl�fo�the valid', of the information I have provided.
���%��r � ?/M - ` �-/�D o� �
�
Signature of Licensed Plumber Registration Numbec
p��v�:�����t�S � " 7 � � �
Type of Registration Date
I recognize that this document shall b come a permanent record of the aforementioned Public Water System and that I am legally
responsible�'or the validity of ' formarion provided.
ti
� � �'�"�`� .,,,i� `'.�' ���-, _ !y����
Signature of Inspector Registration Number
; �>>i�,Y �.;.�, �� � -i y
%.. Type of Registration Date
White-Customers Copy Yellow-City's Copy Pink-Inspactors Copy