2016_0727 CITY OF CUPPELL WATER UTILITIES
CUSTOMER SERYICE INSPECTIOIti
Residential � Commercia{ ❑ TNRCC ID#0570040
1 ,upon inspection of the pmate water distribution facilities lacated at
� ,which is connected t�the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
ln Nan- N(A
Compliance Compliance
{1) No direct conaeetion betw�en tht pnblic drinking watcr supply and a potential � ❑ O
source of contaminatian exists. Foten#ig1 sources of contamination are isolated
frorn the pubtic water system by an air gap or aa a�spropriate backflow preveatioa
assetnbly in accardance wi,th Commission regutarions.
(2) No cross-connccrion between the public drinkiag water supply aad a private water �' O 0
system exists. Where an actual air gap is not rnaintained between the public water
supply and private water supply, an approved reduced pressure-zane backflov��
grevention assembty is properly installCd and a service agreement exists for
annual inspectian and testing by a eertifuedbackflow prevention device#ester.
(3) No conaection existc which would allaw the rettun of water used far condensing � ❑ ❑
cooling or industrial processes back to the public water supply.
(4) No pige or pipe fitting which contains mqre than$.0%lead exists in private water � ❑ ❑
distribution facilities installed on or after July 1, 19$8.
(5) No solder or flux which contaias more than 0.2°!0 lead exists in private water �]"' ❑ �
distnbutian faciliries instaifed on ar af3er July 1, 198$.
Water service shall not be pmvided or restored tr�the private water distr�bution faciliries until the above condirions are determined to be
in compliance.
I csrtify that tlie following materials will be used in the installation of the private water dismbution faciliues located at
�j 5�f���"\)�� and#hat the inspector wili validate compliance duriug the inspectioa process:
Servzce lines Lead D Copper C] PVC ❑ Other � ��"
Solder Lead ❑ Lesd Free � Solvent We1d ❑ Other
I recogaize that this document shall become a pernnaaent record of the afurementioned P�blic Water Sysiem and that I am legally
res ible for the vaiidixy o€the informauon I}�ave provided.
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Sign ture of Licensed Plumber Registration Number
i� m � �-a�-��
Type of Registratian Date
I recogniu that this dacument shall became a permanent record of the aforementianed Public Water System and tbat I am legally
respo �ble for the vatidity of the infomiation pr vided.
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Signa of Inspector Regisoration Number
� �s�n � �I�-� ���
Type o Registrat n Date
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