2013_0701 �'ITY OF COPPELL VVATER iJTILITIES �
�USTQMER SERYjCE INSPECTIOl!
Residsntial i°j �Commereial D TNRCC ID�(15'10040
1- �r°itYv��� �'�`� �Gi,i-,�S '
,trpon inspectAon of the private water dis�ibution facilities located at
� � � L�+ xti �G� ,which is connected to the City of Coppell Water Systeui,do hereby certify
that,to the best of my lcnoivledge:
In Non- N/A
Compli�atce Compliance
(1) No dire�t connecrion between th�e public drinking water supply and a potential t9" � p
source of��ntamination.exists. Aotential soure�s of,contamination are isolated
fram the public water s�stem by sn air gap or an appropriate backflow prevention
assembly in accordance vvitb�mmis�ion re�gulations.
(2) 1'eTa cross-cnnne�t�on bet�veen th�publi�dri�ing vyater supply and a private water t� O p
syst+em exists. �fiere an actual air p,ap is not maintaiped between the public water
supp�y and pzivate wat�r supply, an approved rsduced pressur�zone backflove
prevention assembly is properly installed and a service agreement exists for
axrm�al iinsspectiQn az�d testing lay a certit'ud backf�ow preve�tion dsv�ce tEste�. '
(3) No�ox�►ect�o�+exists wk�ic�i wou�d a�low the retunn of water used for condensing � ❑ p
coo�g or indnstrial processes ba�k to the publie w�ter supply. '
(4) No pipe or pipe fitting wbich contains nnor�than 8.0%lead exists in private water � O ❑
dist�ibutivn facilities installed oa�ar after 7wly 1,i988: � .
{S) No solder or flux which contains nnoxe t3�an 0.2% lead exists m private water Cd" O C]
distributiom facilities installed on c�r aftsr July 1,198$.
Water service shall not be pr�videsl or r�stoz�d to the private wate�r distn'b�tion facilit�es until the atiove conditions are determined to be
in ca�npliance.
9
I cerrify that the followiDg materia wi11 be used in the installation of the privat�water distribuiion facilities located at
I � � � 0�+�� �Q, ` ar�d that#he inspector wall validate compliance during the inspeccion prc�cess:
Service lines I.,ead C7 C�pp�r �]/ PVC C]'/' Other C7
Solder Lcad O I.ead FTee C�" 5olvent Weld 0" Other ❑
I recognize that this document st�all becotne�perman�t reec�rd of t�e aforementioned Public Water System and tLat 1 am iegaily
re onsble fnr validity of the i�t'o. tion I ba�e provided.
a�,-� �l�z�/� ,
ature of Laccnsed P}a�r,nb Registration Number
.�,9�✓1/t-S��Z �'/��'. �
Type af Registrati�n Date . i
I rc�cognize that this document sha11 becotne a permansnt rtcaxd of the aforementioned Public Water System and that I aixi legally
responsible fo�e the validity of the infontnation provided. '
Signature of Inspectpr Registration Number
Type of Registratifla Date
W6i�e-Cusmmc�s Copy Yellnw-Ci�}+s Copy Pmk•1ospMofs Copy