2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residential � Commercial ❑ TNRCC ID#0570040
I �^�y �'o�4c�� ,upon inspection of the private water distribution facilities located at
�o /�/t/(,�� �� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compl'�ce Compliance
(1) No direct connection between the public drinking water supply and a potential � � ❑
source of contamination exists. Potenrial 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 a private water p ❑ ❑
system exists. Where an actual air 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 certified backflow prevention device tester.
(3) No connection exists which would allow the return of water used for condensing � ❑ ❑
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 Q ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water C3" ❑ O
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water dish-ibution facilities until the above condirions aze determined to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distribution faciliries located at
g� /�/C1�0/�/ �f� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ 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 validiry of the info tion I have provided.
.-� _ �1 �� �y �
Signature of icensed Plumber Registration Number
V `�*�✓'(yM,arv � � � l
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 validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
Whi�e-Customers Copy Yellow-Ciry's Copy Piak-Inspectors Copy