2016_0310 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSP TIOI�
Residentfa) O Commercial TNRCC ID#0570040
I Gt, , upon inspection ot the pri��ate water distribution facilities located at
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.3� N. F�y�. r1- I�a�k v�}�LoPPe.1��T1����h�ch is connected to thc City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Com 1� ce Compliance
(1) No direct connection between the public drinking water supply and a potential ❑ ❑
source of contamination exists. Potential 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.
No cross-connection between the ublic drinkin water su 1 and a rivate water � ❑ ❑
(2) P 8 P P Y 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�
prevention 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 ❑ O
cooling or industrial processes back to the public water supply.
°o lead exists in rivate water � O ❑
(4) No pipe or p�pe fitting wh�ch contains more than 8.0/ p
distribution facilities installed on or after July l, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water ❑ ❑
distn�wrion facilities installed on or after July 1, 1988.
W�ur service shall not be provided or restored to the private water distribution facilities until the above conditions ue determined to be
in cofipliance.
I ceRify that the following materials will be used in the installation of the private water dis�ibution facilities located at ,3{,p J�/.
1'�ze.,�c1_}�„fl,.UL� Go�.j�j...�► �1"'�1 7�01� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead O Copper � PVC O Other ❑ _
Solder Lead O Lead Free � Solvent Weld ❑ Other O
I recognize that th' do ment shall become a permanent record of the aforementioned Public Water System and that I am legally
responsibl for th val 'ty of the information I have provided.
- L�� `
Signature o ' en 1 ber Registratio Nu ber
'�� � 3 la ll�
Type of Registration Date
I recognize that this document shali become a permanent record of the atorementioned Public Water System and that I am legally
responsibie for the validiry of the information provided.
r
Signature of Inspector Registration Number
Type o!'Registration Date
While-Cuaomels Copy Yellow•Ciry's Copy Pink-lospeaors Copy