2014_0325 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residential (�" Commercial ❑ TNRCC ID#0570040
I � o-� L ,upon inspection of the pm�ate water distribution facilities located at
�
� , which is connected to the Ciry 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 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 regularions.
(2) No cross-connection between the public drinking water supply and a private water ❑ ❑ C�
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflo��
prevenrion 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 retuin of water used for condensing ❑ ❑ �
cooling or industrial processes back to the public water supply.
4 No i e or i e fitting which contains more than 8.0%lead exists in private water � ❑ ❑
� ) PP PP
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 ❑ � C3�
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 conditions aze detemiined to be
in compliance.
I rtif that the following mate�1 ill be used in the installation of the private water dis�iburion faciliries located at
�J',�� �/�(� N� y 1 � and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead O 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]egally
responsible for the validity the information I have provided.
�- 3G �� �
Sig ature of Licensed Plumber Registration Numbef
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J o�v-�y•.�.,,,
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
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customers Copy Yellow-City's Copy Pink-Inspectors Copy