2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOr
Residential ❑ Commercial ❑ TNRCC ID#0570040
I ^l�'y /���`�� u n ins ection of the rivate water distribution facilities located at
. � � M r r
,which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Comp��l}'�ce Compliance
(1) No direct connection between the public drinking water supply and a potential Q � , �
source of contaminarion exisu. Potential sources of contamination are isolated
from the publir 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 a private water Ca ❑ , O
system exists. Where an actual sir gap is ttot maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflow�
prevention assembly is properly installed and a service agreement exists for
annusl inspecrion an,d testing by4a certified backflow�revention device test�r. .
µ : ;, x _ :� _
(3) No connecrion exists which would allow the return of water used for condensing ❑ ❑ ,: O
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 p� ❑ ,'" O
distribution faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ;� ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities until the above conditions are determined to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distribution facilities located at
�j�lo /�T/LTD/�/ GUA'�� and that the inspector vri11 validate compliance during the inspecrion pmcess:
Service lines Lead � Copper ❑ PVC D Other ❑
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
responsible for the validity o e information I have provided.
- �"- � �4� "�
Signature of Licensed Plumber Registration Number
���Yrw�� �-5-/�f
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validiry of the information provided.
Signature of Inspector Registration Number '
Type of Registration Date
W6ite.Customel's Copy Yellow-City's Copy Piolc-Inspectors Copy