Untitled (2) CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOr
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Residential Commercial ❑ TNRCC ID#0570040
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I `, � 'Q �� ,upon inspection of the pm�ate water distribution facilities located at
��7 `n�, r�� � �r, (�'n�.v-� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge: '
, In Non- N/A
Compli e .�ompliance
(1) No direct connection between the publ}c drinking water supply and a potential p ❑ ,�
source of contamination exists. Poten t�al sources of contamination are i s o l a t e d
from the public water system by an air ap or an appropriate backflow prevention
assembly in accordance with Commissio�pi regulations.
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(2) No cross-connection betaeen 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 approved reduced pressure-zone backflow� � `
prevention assembly is properly instal�ed and a service agreement exists for
annual inspection and testing by a certifi�d backflow prevention device tester.
(3) No connecrion exists which would allo�'�'' the return of water used for condensing p' ❑ ❑
cooling or industrial processes back to tt�e public water supply.
(4) No pipe or pipe fitting which contains miore than 8.0%lead exists in private water Q ❑ ❑
""' distriburion facilities installed on or afte��July 1, 1988.
(5) No solder or flux which contains mor� than 0.2% lead exists in private water g" ❑ ❑
distriburion facilities installed on or after July 1, 1988.
����Water service shall not be provided or restored to the private water distribution faciliries unril the above condirions are determined to be
in compliance. � �i
I certify that the following materials will be used in the installation of the private water distribution facilities located at
:� � and that the inspector will validate compliance during the inspecrion process:
S rvice lines I ✓
e Lead ❑ � opper ❑ PVC ❑ Other L�
Solder Lead ❑ �ead Free � Solvent Weld ❑ Other �
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I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res onsible for the validity of the information I�ave provided.
�'_ /�- G/� � 3
' nature of Licensed Plumber ' Registration Numbec
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Type of Registration ', Date
I recognize that this document shall become a p�rmanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information p�ovided.
�'J - � � 73
nature of Inspector I Registration Number
l� �')') � Ll/S�°S '
Type of Registration Date
White-Cus[omers Copy Yellow-Ciry's Copy Pink-Inspeaors Copy