2016_0315 C]TY�F COPPELT.,WAT�12,UTiLITIES
CUS'J'OMER S�RVTCE.�N6FECTI,Olti
Residentiai [�" - Commercial ❑ TNRCC ID#U57604D
I / O � ` �'�c / upon inspectiQn af tha gri��ate water distrihu#iou faci�itiss 2c�c
G � caced ac
'�� whickz is cflnnecfed to the City of CQppell Water System,do hereby cer#ify
t�at,Fc7 the best o�'rily kna�tledge;
� Nar�- N!A
(1) No direct connection behye�n th$publia dr?nking water suppIy and a potantiai Campliaycs Corrtplianee
source of contamivati.ott exists, Potential sdzuucss of contaminaticu� aze isolated � � • �
fz'om th��Sublic water system by an air gap flr an appropriate baektIow prevention
assemb3y zn accordance with Commission reg�siatians.
(2} Na cross-connecti�n between the gublic drink.ing tivater supply aud a privaie water ^ � D CI
system exists.�Nherc an actu�l air gap is not maintaiued betweeu the pu�lic water
s�ppIy and gr�vate water suPP�Y> � approved reduced pressure-zone h�zckflow �
, prevention assambly is proparly instalied and a $ervice agreement exists for
annuat inspection.and testiug by a certi�ed back#7aFv prevent'ton device tester;
(3) No connectian exists which would aIIow the retum of water used far cnndensing y� p �
{ caoIIIsg or indns�ial processes bactc ta the pnblic water'sugpiy,
{4) Na pipe arpipe f�tting which corrtains more than 8,0°!0 lead exisfs in priv�te water �- CJ ❑
distributian facilitics insrriIled on ar after.JuIy I,I988.
(5) No solder ar flux w3�ich oonfains m.ore that�. 0.2% lead ex.ists in �rivatc water � � �'.-. .. �
dishz'bution facilities iasialled an or after 7u�y I,1�8g,
.. .
Water servioe sha11 nat be ptovided or restored to#he priva#e water riist�'bufion faczlides until the above eoIIditions ate determzued io be
zn cainpliance.
T certify that the fa11���ing materials tvill be used ia the instalIati�n of rhe.przvate water dis�n'burion faciIities I�eated at
�`sy ��"''�"�i� and that tha inspector,uili validate compliance drr�g the inspecrian process;
Service tines Lead O CoPP�' �7 PVC ' ❑ Qtlier �
Solder Lead q I.ead Frce � Solveut Weld ❑ Other ❑
�•
I recagnize tbat this docvment sha11 iiecome a permaneni record of tha af,�rernentionad Puhlic V,Tater System and thai I am Ir.gally
respons��for the valzdity oFt�te infarmatian;ha•re prnvided.
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Szgnature af Lice tl Plumber Re�is�atiiuu�Ntunb�F
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Type of Re�isirarion Date '�
1 recognize that•this d�curi�eni shaII hecome a perniancnt reco e aForemeutioned Public Watez�ystem aud that I am legalIy
respon�le far tfie validity�f the infn tion pravid�
, i , �l�
Signa�ure ox=ix�pecfor Registration Alumber
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TYpe Qf�egis�aEion � Date
Whi¢-�ustnmcfs Cupy YeElow-�qJs Capy
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