2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOr
Residential ❑ Commercial � TNRCC ID#0570040
I 1—rtN�� ��a�'�`C"�� u n ins ection of the rivate water distribution facilities located at
, P� P P
, which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
''In Non- N/A
Compl' ce Compliance
(1) No duect cannection between the public drinking water supply and a potenrial � O ❑
source of contaminarion exists. Potential sources of contaminarion are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commissipn regulations.
(2) No cross-connection betweea the public drinking water supply and a private water p' / ❑ ❑
system exists. Where an actual ait gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflow
prevenrion assembly is properly installed and a service agreement exists for
annual-inspection and testing by a certif ed backflow prevention device tester. �
(3) No connecrion exists which would allow the retutn of water used for condensing Q ❑ ❑
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 C� ❑ p
distribution facilities installed on or after 7uly 1, 1988. `
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ❑
distribution facilities installed on or after July l, 1988.
Water service shail not be provided or restored to the private water distribution faciliries until the above conditians are detemvned to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution facilities located at '
L��QJ' �/�70� W�� and that the inspector will validate compliance duriag the inspection process:
�—
Service lines Lead ❑ Copper ❑ PVC ❑ Other C7
Salder Lead ❑ Lead Free ❑ Solvent Weld ❑ Other ❑
I recognize that this document shall become a perrr�anent record of the aforementioned Public Water System and that I am legally
responsible for the validity of ormation I ha�e provided.
-� � G�y3
Signature of Licensed Plumber Registration Numbec
��N,y.._��. �- s- �y
Type of Registrarion Date
I recognize that this document shall become a permanent record ofthe aforementioned Public Water System and that I am lagally
responsible for the validiry of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White•Customers Copy Yellow-Ciry's Copy Pinlc-lacpeaors Copy