2016 CITY OF COPPELL WATER UTILITIES �
CUSTQMER SERVICE INSPECTIOl�
Residential � Commercial ❑ � TNRCC ID#0570040
I •�,� V �' <�G �Q fZ � �7� ,upon inspection of the private water distribution facilities located at
-])� 5. (',•,�,C;N �I , 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 contamination 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 betwe the public drinking water supply and a private water p" ❑ ❑
system exists. Where an�lac�al air gap is not maintained between the public water r
supply and private water supply, an approved reduced pressure-zone backflo�� �
prevenrion assembly is properly installed and a service agreement exists for �
annual inspection and testing b}�a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing $ O ❑
- cooling or industrial processes back to the public water supply.
(a) No pipe or pipe fitting which contains more than 8.0% lead exists in private water C�" ❑ ❑
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 C'l ❑ ❑
distribution facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities unril 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 distriburion facilities located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑/ PVC O Other �—`
Solder Lead ❑ Lead Free Q' Solvent Weld ❑ Other Gd'
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible�or the validity of the ' formation I have provided.
�? � �I� ?_3
nature of Licensed Plumber Registration Number
R m �°
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
resp sible for lidity of the info ation provided.
��- �� 73
S' ature of Inspector Registration Number
R ✓�'1 � �S�S
Type of Registration Date
White-Customers Copy Yellow-Ciry's Copy Pink-laspeaora Copy