2016_0531 �
!EITY OF COPPE'�LL WATER UTILITIES
- , ` CUSTON�ER SERVICE IJ,VSPECTION
Residential � Commercial ❑ �. TNRCC ID#0570040
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I _ " `-'�— � L'''�' � �-�� ,upon inspection of the private water distribution facilities located at
��7 C G► m e�' o� ,which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Complia� Compliance
(1) No direct connection between the public drinking water supply and a potential ��' ❑ ❑
source of contaminarion exists. Potential sources of contaminadon are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commissiop regutations.
(2) No cross-connection between the pnblic drinking water supply and a private water p' ❑ 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 connecrion exists which would allow the retum of water used for condensing �'" ❑ ❑
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 C'J' ❑ ❑
distriburion faciliries 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 rest,o�red to the private water distribution facilities until the above conditions aze determined to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distribution facilities located at /�� �
_� c+'h'� � ►f'p h and that the inspector will validate compliance duriag the inspecrion process:
Service li�es Lead � Copper ❑� / PVC ❑ Other �
Sol e Lead O Lead Free I�J� Solvent Weld ❑ Other
I recognize that this document shall become a permanent recprd of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
/�'I- 9'z � 3
gnature of Licensed Plumber Registration Number
� YY'� � v,�'/3� �/�
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validiry of the information provided.
/�'I - �� � 3
ature f Inspector Registration Number
� ►�-� �P ��-P.S os/3� /i�
Type of Registration Date
Whiu-Customers Copy Yellow-Ciry's Copy Pinlc-Inspepors Copy
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