Untitled (3) , . � . :. •4 . . , . .
C�TY OF COPPELL WATER UTILITIES
� -�1 CiJSTOMEIt SERVI�E INSPECTIOT
Residential � I Commercial ❑ TNRCC ID#0570040
I � � � ��"�' � ,upon inspection of the pm�ate water distribution facilities located at
� � � , 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 Compliance
(1) No direct connection between the pub ic drinking water supply and a potential p ❑
source of contamination exists. Poten 'al sources of contamination are isolated
from the public water system by an air�ap or an appropriate backflow prevenrion
assembly in accordance with Commissic�n regulations.
(2) No cross-connection between the publicll drinking water supply and a private water L� ❑ ❑
system exists. Where an actual air gap ' 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 certi ed backflow prevention device tester.
(3) No connection exists which would allo I the return of water used for condensing � ❑ ❑
cooling or industrial processes back to tl�e public water supply.
(4) No pipe br pipe fitting which contains I ore than 8.0%lead exists in private water C$' ❑ p
distriburion facilities installed on or afte�July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water �'" p ❑
distribution facilities installed on or afte#July 1, 1988.
Water service shall not be provided or restored Ito the private water distribution facilities until the above condirions aze determined to be
a
�compliance. i
I certify that the following materials will be us�d in the installation of the private water dis�ibution faciliries located at
II and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ opper ❑ PVC ❑ Other Pf
Solder Lead ❑ �ead Free � Solvent Weld ❑ Other �
I recognize that this document shall become a F�lermanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the inform tion Ilhave provided.
�� r�'I- �.z � 3
ature of Licensed Plumber Registration Number
�
Type of Registration Date
I recognize that this document shall become a ermanent record ofthe aforementioned Public Water System and that I am legally
responsible for the v ' ity of the information ovided.
..,_,
!'Y/- �2�.3 Li/S I°�
, ature of Inspector Rggistration Number
(�Y1') {-� w� i��
'1�ype of Registration II Date
I ��"�
� ; ..
White-Customers Copy Yellow-City's CoD7y Pink-Inspeaors Copy
� �