2013_1025 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCC ID#0570040
I �!D�� �����f-�C�K ,upon inspection of the private water distribution facilities located at
�37 ����TpJ�I , which is connected to the City of Coppell Water System,do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compliance Compliance —/
(1) No d'uect connection between the public drinking water supply and a potential O ❑" Cg'
sourFe of contaminarion exists. Potential sources af contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
asseenbly in accordance with Commission regularions.
` (2) No cross-connection between the p�blic drinking water supply and a private water ❑ ❑ pl
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone back#low
prevention assembly is properly installed and a service agreement exists for
annual inspecrion and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the return of water used for c.ondensing � 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 C9� ❑ ❑
distriburion faciliries installed on or after July 1, i988.
(5) No salder or flux which contains more than 0.2% lead exists in private water L� ❑ ❑
distriburion facilities installed on o�after July 1, i988.
� 4 � �
�
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 in the installarion of the private water disaiburion facilities located at ,
U J7 yy��LT�/�� and that the inspector will validare compliance during ttze inspection process:
Service lines Lead ❑ Copper ❑ PVC O Other C9�
Solder Lead ❑ Lead Free Q'� 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 of the information I have provided.
� ---- J- 3���f3
Signature of Licensed Plumber Registration Number
T�11�AlEynlf�'Al 1 �'/2 �"� r 3
Type of Regi'stration Date
I recognize that this document shall become a pecmanent 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
White-Customers CopY Yellaw-Ciry's CopY Pink-Inspeaors Copy