2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial O TNRCC�D{�0570040
I � /`'q`�'� ,u on inspection of the rn�ate water distribution facilities located at
� t r
,which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Comp ' ce Compliance
(1) No direct connection between the public drinking water supply and a potenrial � ❑ ❑
source of contaminarion exists. Pptet�tial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and aprivate water Q ❑ ❑
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��
prevenrion assembly is properly installed aad a service agreement exists for
annual inspsction and testing:by a certified backflow prevention device tester.
� � : / _, , . .
(3) No connecrion exists which would allow the retum of water used for condensing CJ ❑ ❑
cooling or industrial processes back to thepublic water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water [� p ❑
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 distribution faciliries until the above condirions aze determined to be
in compliance.
I certify that the following materials will be used i�the installation of the private water dis�ibuqon facilities located at
gl� /�'1/��O/l� �l�'�r and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC O Other ❑
Solder J.ead 0 Lead Free ❑ Solvent Weld ❑ Other ❑
I recognize that this document shall became a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of information I have provided.
/ '�` v 3(y��l�
Signature of Licensed Plumber RegiStration Number
�r,���,µ,.,, �-�'��
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and thai I am legally
responsible for the validiry of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White•Customers Copy Yellow•Ciry's CoPY Pink-Inspectors Copy.;