2016_0316 CITY OR CQPPELL WATER U�'ILiT'IES
eUST(}MER SERVI��INSFE�TI�1�
�'tesidential �'' Carnmercial C) TNRCC ID#U57UU40
r e.-�'���� � E..`� �...�1 ��.��'�+. ,upun insgection af the p�ieate water distriburion fac�lities lacated at
�`-i-� �,�Qt�f`�t.� �.t� P ,which is connected to ti�e City of Cnppell Water System, do hereby cert�fy
tha#,to the tsest of my knowledge:
In Non- 1'�T/A
Gomgiia��e �ompIiance
(1) 1�Ta direct rannecYian between t3se gublic drinking water supply and a pc�cential 1� ❑ C1
source of contamination �xists. Potential sources of cant�minatian are isoIated
frQm t�e public water s�stem by an air gap or an appropriate baekflaw preveurion
ass�misly in accordance with Comrsussi�n regularions.
(Z) No cross-connection between tl�e public drinking water snppiy�d a private water C'� ❑ p
system exists. 't�Uhere an ac#ual air gap is not rnaintained between the public water
supply �nd private water sc�pply, an approved reduced pr�ssure-zone bac�ou�
prevention assembly is property installed and a service agreernent exi�ts for
annual inspection and testing by a certrfied backflow prevention device tester.
(3) No con.neciion exists vvhi�h wauld allowv the retum of water used fior condensing � p p
coalut�os industrial prueesses back ta tt�e public water suppty.
(4) No pipe ar pip��tting which edn�ain$more than$.0°!0#ead exists in priva#e�?vater �,1 p ❑
dis#ributiazt faeiiities inc#al�ed on or after July 1, 19$8.
(5� I�to salder or flu�c whicb contains mare than Q,2% lead exists in private water [� p p
distribu#ion facilities installed on or after July I, �988.
Water scrvice shall ncst be provided or resttrred 10 the private water distnbution facaiities until the above canditic�ns are deternuned to be
'ru cornpliance.
I certify�rat ihe fallowing materials will be used in the instaliation of the private water dis�-ibvtion faci3iries located at
L`i� f� �' �,� �1 (� ��' C`� and that the�nspectar wiil validate camp�iauce during the inspection prc�ce�s:
Service lines L.�ad O �opp�r D PVC ❑ Other � �i�.ijL:
S€alc�er Lc�d ❑ Lead Free l7 5olvent Weld CJ Q�her
I recognize that this document skali become a permanent record of fihe aforementioned PubliG Water Syscem and tl�at I am Iegally'
res �ble for the vatidity af the infarniarion i ve prc�vided.
� � �f�. � ��7
Sig' ture of Licensed Flumtser Regis�ation Number
� �l. � �-- ��-- (1,�,
`Type of Registmtion Date
I recagnize that ihis ducument shall become a pernaan�nt recard c�f the aforementioned Public Water Systerrr and that I am legally
res �ibte for the vaiidity af ttYe info tion pr vided.
� l ' c���'%z- �`_ ���- -- �
S1gn ture vf Trispector Regxstration Numb�r �
� � .L�?�� �' � t��r�
Ty}se of Registrati+�n p�t�
Whitt-L�sibmeta CtiPY Yollow•City's Copy Pink-laspeao�'s CoPY