2016_0302 (2) CITY()F COPgELi,�NAT��UTIL�TIES
C�7STQMER SERVICE�SPECT10Iti
Residentiai � Comrnercia! ❑ TNRCC7D#�57UD40
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I �f � ���` upon inspe�ti��af thc grivat�water dis�ihuiion facilities located ac
?�� ��''Jf��4 de e �wkuch is cnnnecied Lo tlxe City of Coppell Wzter System,do hereby cez#iC}�
: that,io the k�est of my knauRledge;
� Non- T�IA
Cam lp iac�e �ampliance
(I� No d'uect connection betr,veen the pubtia drznking water suppIy and a ggtential � • p p
saurce of contamination exists. Pr�tant�al sourc�s af c�tarizinatiorn a.re isolated ' '
from the pnhlic v,tater system by an air�ap or an appropriate backflow pxeuer�tion
assembly in accoxdance with Cou�.niissinn regulations.
(2� Na crBss-connection between fhe gubIic clrFn�r.ing water suppiy aud a privaie water � p 0
system exists.�1�Ihera an actual au gap is n9tmainfained between the public.3vater
st�ppIy and private water snPPIY, au apprflved racluced pxessvre-zns�e �Sacktinw .
, prevention assembly is pcoperl}r itysta]ied and a service agreement exists fnx -
annual inspectionand testing by a aertified hack#]�w presrention device tester:
(3) No cnnnecdan exists tiyhicl�wauld aIlvw the retuzn af water uses�f.oz condensin� � p n
} cooI'mg nr�ztdus�zal pro�ess�s back ta the pubJ.ic lvater supply,
(4) Na pipe arpipc fitiszcg vsrhich contains mare than 8.0°/a tead exists ir�private water �- p ❑
distribnqan faci�ities insraIled on or after.7uty I, 1988.
��) Nd SO�C�EF OL' tIUX VT�11C�2 COA�IIILS SF107S than 4.2°/a lead exists in �vatc water � � . p -_ . .. p
dish�'bution facilz#irs instaTled an or after July I,I988.
*,. .
Wafer service shaTl n�t be pravided oz restored to fhe private water disttil�ution facilities un[il the above eouditi.ons are detenntned io be
in camp3iance.
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I certify thaE the fa1I4�-ing materials�ril}6e used in the installaEiaa of the�zivate wa#er dism`bution facilities lr3cated at
and that the inspector will vatidate compliance dtuing the inspection pracess:
�ervice liaes Lead ❑ Coppec ❑ PVC ' L7 Ot19�r /�
Solder �.,ead C1 7.�ad Free � Solveat Weld D QFher Q
I recognize that this doc�rtzent shail become a pe #rccard of the aforemeritianed Public Wates Sysiczti and that I am Iegally
respons�b�for the vaIidi of the inforna� ' hava pravided.
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5�gnature af Li d Flumhar Regfstration•NumbeF
ws',of � 3,�Z /�
Type of Regis�arifln I3ate
1 recogztize that�this document shzlI become a pertnancnt recurd o . forcmentiQned Publi�Water System aud that T am IegalIy
r�spon,�}5Ie far t�e vali 'ty af rhe ' rmation a�' „
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S3gI1ah]xe 4�Z pecco Registrat�on Ntunber
�✓s��' � �_ 2 'l�
Type of Regis�at:pn Date
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