2016_0302 CITY QB COPPELL WAT�R UTR,�TIES
C�TSTC3MER�ERVICE�NSPECT.IOi'd
Residentiai � Commereial ❑ TNRCiC ID#�57U04D
�j /� -,r- / ,
Z �- ��--vY -� " �i/C��( _ ,upon mspeotion of the grivat�wa[er dis�ihuiiou facilities lncaced at
— 7�3 �71v.✓T,;vQaQ�j,�� ,tiy�G�����Ecied to the City of Cappe]!Water System,do hereby cer#ify
: that,ra the hest of my kxtpwledge;
� Non- T�(!A
�nmpliance �arrtpliance
tl)� Nv duect cannectian between Yhc publia drin}ciug water supply and a potential � ' Q ❑
source of contam.ination exisu, Potenbal sourc�s af a�tar�zination are isolated ' �
fram the publi�water syste[n by an air gap or an appro�s-i�te backflvw preveatian
asse7nbly in aceordance with Conunission regulatians.
(Z} No crass-connection b�twceu the gui�Iic drinking water suppiy aud a pr�va#�water � p �
system exists,�l�hera an actual aix gap is naf maintained batwecn the pubIic water
supgIy and grivate water snPF1Y, su apprflved reducr.d pressure-zone backflo�� .
, preventian assembly is properiy znstalied and a service agz�ement exista for -
annual inspection and testing by a cecti#ied backflaw prevention devjce fiester:
(3) No connection exisis whicfi wo�Id aIIow the rcturn af�vater used for condensing � 0 n
{ aooI'mg or indns�i.al processes bar,lc to tfie publzc�vater'supply,
{4) Na pige orpipe�ittizzg vsrhich contains m�re rhan 8.0°la Iead exists in przvate watez �� CJ O
dis�ihndan facilities instaIled on or after..TuIy I,1�88.
(S) No soider or tlux v�3zich confains mare than 4.2°/a lead ex.zsts in ��at� water � � . p •_ . .. �
distrx'bution fa.czizties insta]]ed an or after 7u1y I,1�88.
*,. .
Water service ahaIl nat be prgvided or restored to the private water disttibution fac�i.ries until the above eanditi,ous are deteim.tned zo be
in coinpliance.
I certify that the falIos�-ing materials wiT1 be used'zu the ictstallati�n of the.private v�rater distn'bution faciliti.es ir5cated at
_ �7s �ii�wr.�,✓4 d'a,�, aad that the inspecfiQr wiIl validate coznpJzance dtus"ng the znspecrion pracess:
,
�ervice Eines Lsad D Cogpe� fl PVC ' p Q�
5older �,ead Ct X.ea.d Frea �' Solvent We2d D OFhcr Q
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I recoe;'e that tb#s dacument sk��il liecome a pezmanent recazd of tf�e afarementianed Public Water Sysiem and that I am Iegally
respons�b�for the vaIidity of the infomiation i�av� �ovided.
� , '
Signature af Lice rI P}umber - �"� .
RegistraEion.Number
G✓ S '°f 3- 2 /�
Type flfRegisirarion Date
�recognize that�thhis d�cument shall become a germanent recazd af.the aForemeutianed�ubli�Watez System and Chat I am lcgally
r�spon�hIe fa the validity af rhe mfarmation '��----
+a�i� /�
Signatare of I pecta Registra#�an Number
� sI' f , E
Typc ofRegis�ztion - �? ��� •
Date
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