2014_0107 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residential � Commercial ❑ TNRCC ID#0570040
I �' � ,upon inspection of the private water distribution facilities located at
� .� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowl�dge:
�` In Non- N/A
Com liance Compliance
(1) No direct connection between the public drinking water supply and a potential � ❑ p
source of contaminarion exists. Potenrial sources of contamination are isolated
from the public water system by an air gap or an appropriatc backflow prevention
assembly in accordance with Commission regularions.
(2) No cross-connection beriveen the public drinking water supply and a private water (� ❑ p
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 cyonnecrion exists which would allow the retum of water used for condensing � p ❑
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 I�d' ❑ ❑
distribution facilities installed on or after July 1, 1988. ��
(5) No solder or flux which c�ntains more than 0.2% lead exists in private water � ❑ ❑
distriburion 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 are determined to be
in compliance.
I certify that the following materials will be used ' the installation of the private water distriburion faciliries located at
_7�J ��(�U(�i// fl'�,�� and that the inspector will validate compliance during the inspecrian process:
Service lines Lead Copper ❑ PVC ❑ Other ❑
Solder Lead Lead Free ❑ Solvent Weld O Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsi f the information I have provided.
' __ J��'3
Signature Registration Number
,- � ,✓ /- �- /
Type of Registr on Date 'T
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legaily
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customers Copy Yellaw-City's CoPY Pidc-Iaspeaors Copy
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