2016_0630 CITY C)F COPPELL WATER U"TILI7IES
CUSTOMER SERVICE Il'�ISFECTiON
Residential C�, Commercial ❑ TNRCC ID�Q570Q40
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I `�-' , upon insgection of the private water distribution facilities located at
� ,which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knawledge:
ln Non- N1A
Com liance Cflmpliance
(1) No d'utct connection between the public drinking water supply and a potential � p �
source of contamination exists. Potentia[ saurees of cantamination are zsolated
from the publi�w�ter system by an air gap or an appropriate backflow prevenrion
a�sernbly in accordance with Commissian regutations.
(2) No cross-co�action between the gublic drink.ing water supply anci a private water � p �
systern exists. Where an actual ait gap is not maintained between thc pubfic water
supply and private water supply, an approved reduced pressur�-zone baekflou�
preventian assembly is properly installed and a seruice agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3} No connecrian exists which would a11aw the ret�irct of water used for condensing � d 0
coaling or industrial processes back ta the public water supply,
(4) No pipc or pipe fitting which cantains more than$.0°10 lead exists in private water {g � Q
distribution facilities installed an s�r aft�r July 1, 1988.
(S) No solder or flux which contains more than d.2% lead exists in private water � p �
distribution facilities insCalled on or after July i, 1988.
Water service shaIl not be pravided ar restored to the private water distribution facilities unril the above candirions aze determined to be
in compliance.
I certify that the following materials will be used in the installation af the private water dis�ibutian facilities Iocated at
� �-���� �' and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper L� PVC I� �ther t'd� �C��
Soider Lead ❑ Lead Free O Solvent Weld Q Other 'I�
I recognize that this document shali become a permanent record of the aforementianed Public Water System and that I am legally
res ibie for the validity of the information I have ovided.
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Sigrt re of Licensed Plumber Reg�stratton Nurobef
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Type of Reg�stration pa��
I reco ize that this document shall became a permanentrecard af the aforerr►entioned Pubiic Water System and tkaat I am legally
resp ible for the validiry of the information pravid
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Sign ture of Inspector � RegXstration Number
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Type of Registra2i n Date
White-CuStomeYS Copy }'ctlow•Ciry's Cppy p�_���nor��aP�,