2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential �� Commercial 0 TNRCC ID#0570040
I ���'"'�� �10��`'��G ,upon inspection of the private water distribution facilides located at
�j,�� /��/L�j)/l% ��/�-� ,which is connected to the City of Coppell Water System, do hereby certify
�
that,to the best of my knowledge:
In Non- N/A
Compli ce Compliance
(1) No d'uect connection between the public drinking water supply and a potential � O ❑
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 backflov��
prevenrion assembly is properly 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 return of water used for condensing p'` ❑ ❑ 1°
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� ❑ ❑
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. j,, ;,. ,
;
, _ y, . , , , _ _
Water service shall not be provided or restored to the private water dishibution faciliries until the above condirions are determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water dis�-ibution facilities located at
8.3� �'��LTd�� �� and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other ❑
Solder Lead O Lead Free ❑ Solvent Weld ❑ Other 0
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 ' rmation I have provided.
;�- J 3�9 �' �
Sigriature of Licensed Plumber Registration Numbec
"�,► ��^r_,��,M�Ls�. �— �' ��( . �
Type of Regis�ation 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
White-Customels Copy Yellow-Ciry's Copy Pidc-laspeaors Copy