2013_0926 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential Commercial O TNRCC ID#0570040
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I '�� �/CJ��G� u n ins ection of the rivate water i '
, po p p d stnbution facilit�es located at
�Q�p i�'I�w+ WG�` , 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 direct connection between the public drinking water supply and a potenrial O ❑ B�
-�4 source Qf contaminarion exists. Potenrial sources of contamina6on are isolated
from theq public water system by an sir gap or an appropriate backflow prevenrion
� assembl'�in accordance with Commission regulations.
�
(2) No cross-connection between the public drinking water supply and a private water O ❑ �
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
prevention assembly is praperly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
� (3) No connecrion exists which would allow the retum of water used for condensing C�'�r ❑ ❑
cooling or indus�ial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water � ❑ ❑
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 �'" p ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distriburion faciliries until the above condirions are determined to be
in complianca
I certify that the following materials will be used in the installation of the private water distriburion facilities located at �b�
/�� j�'v Eil�i `/ and that the inspector will vatidate compliance duriag the inspecrion process:
Service lines Lead ❑ Copper �— / PVC ❑ Other Cl
Solder Lead ❑ Lead Free C3� Solvent Weld ❑ Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res�onsible for the vali 'ry of the inf ation I have provided.
� 3�9y,� rt
,
Signature of Licensed Plumber Registration Number �
`To�,�,�.�„ q�i� l3 '
Type of Registrarion Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally a�
responsible for the validiry of the information provided.
,:<.
Signature of Inspector Registrarion Number
���.
Type of Registration Date
White-Customers Copy Yellow•Ciry's Copy Piok-Inapectors CopY
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