2016 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential � Commercial ❑ TNRCC ID#0570040
I �.J�'� � u R '� '�f"� ,upon inspection of the private water distribution facilities located at
� I �l �.�;vti, � . ��Gn , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compli ce Compliance
(1) No direct connection between the public drinking water supply and a potential � O ❑
source of contaminarion exists. Potential sources of contamivaation 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 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 backflov��
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 rehun of water used for condensing Q ❑ ❑
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 p� ❑ ❑
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 � O ❑
distribution facilities installed on or after July 1, 1988.
Water service shall not be provided or restored ta the private water distribution facilities until the above condirions aze determined to be
in compliance.
I certify that the following,materials will be used in the installarion of the private water dis�ibution faciliries located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC 0 Other Q�
Solder Lead ❑ Lead Free � Solvent Weld ❑ Other �'�
I recognize that this document shall become a permaneat record of the aforementioned Public Water System and that I am legally
responsible for the validity of the informatio �rovided.
. �7 - !17 3
nature of Licensed Plumber Regist�ation Number
� l�'1 P �
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and thaf I am legally
responsible for the validity of the informarion pro�cided.
��-- y Z � 3 w.s�°s
i nature of Inspector Registration Number
� n'� f 1�v� �'s
Type of Registration Date
White-Customers Copy Vellow-Ciry's Copy Pinlc-Iaspeaors Copy