2013_0917 (2) /; '
CITY OF COPPELL WATER UTILITIES
, CUSTOMER SERVICE INSPECTIOT
Residential � Commercial ❑ TNRCC ID#0570040
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I �('�N N I � � � I k��� ,upon inspection of the private water distribution faciliries located at
I��! .�h Ac��. (��N L t� �i+hich is connected to the Ci of Co ell Water S stem do hereb certif
ti ��c C]� tY PP Y , Y Y
that,to the best of my knowledge: �
In Non- N/A
Compliance Compliance
(1) No direct connection between the public drinking water supply and a potenrial '�_ Q ❑
source of contamination exists. Potential 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 � ❑ ❑
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 connection exists which would allow the return of water used for condensing '� ❑ [�,w
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 � ❑ ❑ ,
distriburion facilities installed on or after July 1, 1988.
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(5) No solder or flux which contains more than 0.2% lead exists in private water y� p ❑ {
distribution facilities installed on or after July 1, 1988. �� � ;:�.
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Water service shall not be provided or r4stored to the private water distribution faciliries until the above condiripns 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 � �' �
� ' C�t, [!4t t° l���p �g(k���i n � and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other 'l� �E�
Sold�r � Lead ❑ Lead Free ❑ Solvent Weld ❑ Other �
I recognize,that this document shall become a permanent record of the aforementioned Public Wat�r System and that I am legally
re�p`onsi��:����ie validity of the info rion have provided. � �
� `� � � � � ��o � �
re of Licensed Plumber Registration Number
���,-�� � q - ��- � �
,Type of Registration Date
I recognize that this doeument shall become a peimanent record of the aforemenrioned Public Water System and that I am legally
r�'"sponsible for the validity of the inf ation rovided.
'�`'� -�, � `�� -w � � �--- 3������ � � �
Sign�ture of Inspector Registration Number
��,� �` _� �` �- i `� - �I �
Type of egistration Dat
White-Customers Copy Yellow-City's Copy Pink-laspeaors Copy