2015_1217 CITY OF COiPPELL WATER UTILITI�S
CUSTO�R SERVICE INSPFCTION
Residential C� Commercial � TNRCC ID#0570040
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I `�'�� ����'� ,upon inspection of the private water distribution facilities located at
/� �.� /��''E"� �l�`'�/•, which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowle ge:
In Non- N/A
Compliance Compliance
(1) No direcf connection between the public drinking water supply and a potenrial C�'� Q ❑
source of contaminarion exists. Potenrial sources of contamination are isolated
from the public water system by.an air 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 � O 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 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 L9'" 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 ❑ ❑ [��
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which,contains more than 0.2%0 lead exists in private water p p ��
distribution facilities installed on or after July 1, 1988.
Water service shall not be provided or zestored to the private water distribution facilities unril the above condirioas are determined to be
in compliance.
I ce ify that the following materials will be used in the installarion of the private water distriburion faciliries located at ��/
�� � � .�-�- • and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other O� ��
older Lead O Lead Free ❑ Solvent Weld ❑ Other ��
I recognize that this document shall become a permanent record of the aforementioned Public W�ter System and that I am legally
responsible or the validiry of the information I have provided. �
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Sign re of Licensed Plumber Registration Numbe ��
vV�/�� �
Type of Registration Date
I recognize that this document shall become a permanentrecord of the aforementioned Pubiic Water System and that I am legally
responsibl r the validity of the information provided.
� ���,�'�i���
Sig�a�fure of�t�� Registration Num�gr
.J � ���,(
Type of Registration Date °'
White-Customers Copy Vellow-City's Copy Pink-Iaspeaors Copy