2016_0613 C'ITY('JF'CUPPELL WATER UTILITI£S
CUSTOMER SER�'ICE INSPECTIO�+
Re�identia! i�. Commerci�l � TNRCC ID#�570a40
I �� '�. ,upan inspection of fhe prnrate water discribution facilities located at
�� 1 ��t'P �t'�st,� � , whtch is connecteti ta the City af Coppeil Water 5ystem, do h�reby certify
that,ta the best of my lrnowledge:
In Non- NIA
Compliance Compliance
(1 j No direct connectian between the public drinking water supply and a potential � [] ❑
source of contamination exists. Poteni�al sources of contatnination are isolated
fram the pubFic water syst�m iay an air gap or an appropriate backflaw prevenriaa
assembly in accordance wiih Cammissiun;regu�ations.
(2) No cross-eonnearion between the public drinking water supply and a priv�te water � p p
system exists, Where an actu.al aiz�ap is not maintained between the puhlic water
supply and pri�ate water supply, an approved rednced pressure-zone backflow�
prevention assembly is prup�tly instatfed and a sefaice agreement e�sts far
annual inspectian and testing by a certified backflow prevention device tester.
(3) Na connectitm exists which would allaw the retum of water used for condensing � p p
cooling or indus�rial prvicexses back to the public water suppty.
(�l) No pipe or pipe�tting which cantains mare than 8.0°fo lead exists in private water � p p
distributian facilities installed an ar after July 1, I988.
{5) No solder or flux which ccrntains more than 0.2°/n lead exists in private water f�d" p p
disixiburion facilities ins#alled an or after July 1, 1988.
Water service shall aot be provided or restored to the private water distributian facilities unrii the above conditions are detemuned to be
in campliance,
I c�rtify that the follovring materia3s will be used in the installation of the private water dismibution facilities located at ��"��
�1.����' ss.��(-���` and that the znspectar wi11 validate compliance during the inspecri�n process:
Servicelines Lead 0 Capper Cl FVC O Other �. ��
Solder Lead � Lead Free ❑ Solvent Weld Ci Other I�'
I recognize that this dactunent shall become a permaneat recard of the afaremenrioned Puhlic Water System and tl�at I am tegaI]y
res sible for the validity of the infc�rmation I have provided.
P
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Stgn e of Licensed Plumber Regisaration Numbe�
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Type af Registration Date
I recognize that this doeutnent shall becarrme a permanent recard trf the aforementioned Public Water 8ystern and that I am legally
resp ibie far the validity of the informa" provi ed
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Sign re of Inspector Registratian Number
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Type of Registration Date
WEtite-Cu5Wmers Copy 1'cllow�.Ciry's CapY Pirtk-Impccrnr`s CoPY