2016_0422 CITY OF CQPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIO'�
Residential � Cammercial ❑ TNRCC ID f►Q57Q040
I � , upon inspection of the pri��ate water distribution facilities lacated at
, which is conn�cted to the City af Coppell Water System, do hereby certify
that,to the best of my kn�rvvledge:
In Non- N�A
Gomplianc� Compliance
{1) Na direct connection betwe�n the public drinking water supply and a potentia] � ❑ ❑
source of contamination exists. Potentia} souzces af eontamination are isolated
from the public water system by an air gap or an appropriate backflaw prevention
assembly in accordance with Cammission regulation.s.
(2} No cross-connection between the public driatking water supply and a privatc water � ❑ �
system exists. Wtiere an ackual air gap is not maintained between the public water
supply �nd private water supply, an approved reduced pressure-zone backflou�
prevention assembly is properly installed an� a service agr�ement exists for
annuai inspeczion and testing by a certified backflow prevention device tester.
(3) No connection exists which would atlow the retum of water used for candensing (� ❑ ❑
cooling or indusbnal processes back to the public water supply,
(4) No pipe or pipe fitting which contains more than$.0%lead exists in priwate water '�L ❑ ❑
distribukion faci�ities installed on o€after)uly 1, 1988. �
(5) No solder ar flux which contains more than (1.2% lead sxists in pnvate water � Cl ❑
distribution facilities installed on or after July 1, 1988.
Watez service shall not be provided or restared to the private water distribution facilities until the above conditions are deteimuied to be
in compliance.
I certify th tthe following rnaterials will be used in the instaliation of the private water distriburion facili[ies located at
��� �3��� �����, and that the inspector wili validate compliance durimg th�inspection process:
Service lines Lead ❑ Copper ❑ PVC � ���r �` ���
lder Lead ❑ Lead Free ❑ Solvent Weld ❑ Other L�,
i re ognize ttiat this document shail beeome a permanent zecord of the aforementioned Public Water System and that I am legally
re a sible for the vaiidity of the informa �on I h ve provided.
� �
Si re of Licensed Plumber Registration umber
�h� � -�� - �,�-
Type of Registration I7ate
I recognize that this document shall become a permanent reoord of the aforementior►ed Public Water System and that I am legally
re a sible for the validiry of the informatio provid .
�� �� ���
S�gn re of Inspectoz Regis�ation Number
�--i '�C�C�'� —
Typ� of Registr tic�n I�atc
While-Cusiortxrs Copy Ycl:low�-City's Copy Pink-laspeao�a Copp�