2014_0624 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCC ID#0570040
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I ,upon inspection of the private water distriburion facilities located at
9�v� c�/���lv.S'f�i(L T R9L , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compli ce Compliance
(1) No direct connection between the public drinking water supply and a potential ❑ p
source of contamination exisu. Potential sources of contamiaation are isolated
from the public water system by an air gap or an appropriate backflow prevenrion '
,y
assembly in accordance with Commission regularions.
(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 thepublic water
supply and private water supply, an approved reduced pressure-zone backflow
prevention 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 11Y O O
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 L9� ❑ ❑
dis�iburion facilities installed on or after July 1, 1988.
(5) , No solder or flux which contains more than 0.2% lead exists in private water q/ ❑ ❑
` distn`butibnf facilities installed on.o'r sf'ter July 1, 1988. '" ',�`` ' , � . ' ,k. _
Water service shall not be provided or restored to the private water distribution facilities until the above condirions aze determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water distriburion facilities located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead 0 Copper ❑—/ PVC B/� Other C� ���,}�
Solder Lead ❑ Lead Free Iff Solvent Weld L7 Other ❑
I recognize that ' document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsib ' i o e information 1 have provided.
Sign re o cense lumber Registrari n Numbe�7�
/l�i/,lS�,C' -�P - ,z Ll- /y
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 validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Cuuomers CoPY Yellow-Ciry's CoPY Pidc-fospeaors CoPY