2016_0519 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential Commercial ❑ TNRCC ID#0570040
I � O � _,..i� � R 2�'f � ,upon inspection of the pm�ate water distribution facilities located at
��� ..� . �t7 ��� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge;
In Non- N/A
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Complia Compliance
(1) No direct connection between the public drinking water supply and a potential � p ❑
source of contamination exists. Potenrial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water �f ❑ ❑
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 backflaw prevention device tester.
(3) No connection exists wttich would allow the retum of water used for condensing � ❑ ❑
cooling or indus�ial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water � ❑ ❑
distriburion 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 until the above condirions are determined to be
in compliance. ,
I certify that the following materials will be used in the installation of the private water disuibution facilities located at ���
�. Gc� p p � �I and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other C-3'/
Solder Lead ❑ Lead Free � Solvent Weld ❑ Other C�'
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that T am legally
resp nsible foyth validity of the information I have provided.
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nature of Lice ed Plumber Registration Numbef '
� y�� � o.� �
Type of Registration Date �/
I recognize that this document shall become a petmanent record of the aforementioned Public Water System and that I am legally
responsible for th 'dity of the info ation provided.
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i nature of In ector Registration Number
R ri 1 f,�`S �s C�S�/y //�
Type of Registration Date —�
White•Customers Copy Yellow-Ciry's Copy Pinlc-laspeaors Copy