2016_0323 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residential O Commercial ❑ TNRCC ID#0570040
I ��� � , upon inspection of the pnvate water distribution facilities located at
� - a , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compliance Compliance
(1) No direct connection between the public drinking water supply and a potential ,0� ❑ ❑
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 ,0� ❑ ❑
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 connecrion exists which would allow the retum of water used for condensing � ❑ 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 � ❑ ❑
distribution facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities unril the above condirions are detemuned to be
in compliance.
I certify that th ollowing materials will be used in the installation of the private water distribution faciliries located at
� L
�Q-•L1—�`e and that the inspector will validate compliance during the inspecrion process:
�ervice lines Lead ❑ Copper ❑ PVC ❑ Other ❑
o er Lead ❑ Lead Free ❑ Solvent Weld ❑ Other ❑
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsib for the validity of the information I have provided.
' �-�Lqsy
Signature of Licensed Plumber Registration Numbee
�u��� � �� � '�Y
Type of Registration ate
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible f r the validiry of the information provided.
- -�- �� �SY
Signature of Inspec or Registration Number
��.�.-•r�r�/ _ I�- �1�� l 2��-
Type of Registration Date
White-Customets Copy Yellow-Ciry's Copy Pink-laspeaors Copy