2014_0414 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOI�
Residential � Commercial ❑ TNRCC ID#0570040
/ '
I -�'iicJd ,upon inspection of the private water distribution facilities located at
s' � ie,� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Com liance Compliance
(1) No d'uect connection between the public drinking water supply and a potential � ❑ ❑
source of contamination exists. Potenrial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
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 backflow
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 �] ❑ ❑
cooling or indus�ial 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.
(5) No solder or flux which contains 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 unril the above condirions aze determined to be
in compliance.
I certify that the following materials wil e used in mstallation of the private water dis�ibution facilities located at
�� �iII l�G�L���/��%4i � and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC Other O
Sol er 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 for the validity of the informa ' n I have provided.
� 3 6 �' s/—�
Signature ensed P mber Registrati n Number
� �o �j� /G
Type of Regi 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 validiry of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customds Copy Yellow-Ciry's Copy Pink-Iospcctors Copy