Untitled r , C�Y OF COPPELL WATER UTILITIES
STp�SEIt�1.��I1�SxPE�TIOr
Residential � �' Commercial ❑ TNRCC ID#0570040
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I �"� �u `R � '� �, ,upon inspection of the prn�ate water distribution facilities located at
�(�(���:,������.-� I' , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge: '
II In Non- N/A
Compli e Compliance
(1) No direct connection between the pub�ic drinking water supply and a potential � O ❑
source of contamination exists. Poten�ial sources of contamination are isolated
from the public water system by an air�ap 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 � ❑ ❑
system exists. Where an actual air gap i�'�not maintained between the public water
supply and private water supply, an a�proved reduced pressure-zone backflow�
prevention assembly is properly insta�led and a service agreement exists for
annual inspection and testing by a certif�ed backflow prevention device tester.
(3) No connecrion exists which would allo�v the return of water used for condensing B' ❑ ❑
cooling or industrial processes back to tt�e public water supply.
(4) No pipe or pipe fitting which contains r�ore than 8.0% lead exists in private water � ❑ ❑
distriburion facilities installed on or afte�July 1, 1988.
(5) No solder or flux which contains morl� than 0.2% lead exists in private water � ❑ ❑
distriburion facilities installed on or afte�July 1, 1988.
Water service shall not be provided or restored ilto the private water distribution facilities unril the above condirions aze determined to be
in compliance. i
I certify that the following materials will be usq�d in the installation of the private water dis�ibution faciliries located at �
�' and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ II o er ❑ V
pp P C ❑ Other �
Solder Lead O �ead Free � Solvent Weld ❑ Other
I recognize that this document shall become a p�ermanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I jhave provided.
ri� - �z � 3
i re of Licensed plumber ! Registration Numbee
� rrJ f� ',
Type of Registration ', Date
I recognize that this document shall become a�ermanent record of the aforementioned Public Water System and that I am legally
responsible for the v lidity of the information p'�ovided.
/�'I - %� � 3 �-f�'S
S' ature of Inspector i Registration Number
� � T �� S ► � �
Type of Registration '� Date
White-Customets Copy , Yellow-Ciry's Copy � Pinlc-faspeaors Copy