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CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION ,
Residential GV� Commercial ❑ TNRCC ID#057004
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I �.�-.�^�P.�`1 � �n���� ,upon inspection of the private water distribution facilities located at
��J'1 �Now51�F� �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
Compliance Compliance
(1) No d'uect connection betwe�n the public drinking water supply and a potential p p [�'�
source of contamination exis�s. Potential sources of contaminarion are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
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 the public 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.
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(3) No connecrion exists which would allow the return of water used for condensing �d � ❑ ❑
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 faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water l� ❑ ❑ `
distnbution facilities installed on or after July 1, 1988. �"
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 installari�tt of the private water disa-ibution facilities located at �
��N� �� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead � Copper �/ PVC ❑ Other �
Solder Lead ❑ Lead Free C� Solvent Weld O Other O
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validi f the information I have provided.
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Signature of Licensed Plumber Registration N mber
J OL/N L y'M��v ��Z f!��
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•Customers Copy Yellow-Ciry's Copy Pidc-Inspeaors Copy'