2014_0108 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential Commercial ❑ TNRCC ID#0570040
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I �'�� � ,upon ins�ection of the private water distribution facilities located at
�`t�� �A/(`(J�1;�"!L L , 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 Compliance
(1) No d'uect connection between the public drinlcing water supply and a potential � Q ❑
source of contamination exists. Potential sources of contamination are isolated
from the p�blic water system by an sir 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 � p ❑
system exists: Where an actual air gap is not maintainedbetween the public water _
supply and private water supply, an approved reduced pressure-zone backflow� F
prevenrion 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 conne�rion exists which would allow the return of water used for condensing � ❑ p
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains�nore than 8.0%lead exists in private water p/ ❑ ❑
distribution faciliries installed on or after July 1, 1988.
, �'
(5) No solder or flux which c�ntains more than 0.2%'lead exists in private water t� Q ❑
distribution facilities installed on or after July 1, 1988. , �
Water service shall not be provided or restored to the private water distribution facilities unril the above condirions are detemuned to be
in complianee. ��
I certify that the following materials will be used in the installation of the private water dis�iburion facil�s located at
�jj�s 5/VD(AJSFF�LL TipL • and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC O Other C3�
Solder Lead ❑ Lead Free ❑ 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 th alidi f the information I have provided.
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Sign re of Licensed Plumber Registration Number
Ju�.r,�c�r�- I --�' �� ''(
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsi'ble for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date `
White-Customers Copy Yellow-Ciry's Copy Pinlc-Inspeaors Copy