2016_0914 ,� �
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} �' '" CIT�OF COPPELL WATER UTILITIES
' __j ��JSTOMER SERY�E INSPECTION
Residential � Commercial ❑ ' TNRCC ID#0570040
I (�� � � �t IQ � �f 7 ,upon inspection of the pm�ate water distribution facilities located at
7�,� !/��,�-chc� , which is connected to the Ciry of Coppell'Water System, do hereby certify
that,to the best of my knowledge:
..�n , . Non- N/A
Compli3� Compliance
{1) No direct connection between the public drinlcing water supply and a potential ' Pd" � ❑ ,
source of contamination exisu. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accnrdance with Comcnission regu�ations.
(2) No cross-connection between the public drinking water supply and a private water � ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approyed reduced pressure-zone backflov��
prevek�rion assembly is properly installed'and a service agreement exists for
�"nnwal inspection and testing by a certified bac�c,tlow prpvention device tester.
(3) No connecrion exists which would allow the return of water used for condensing �; ❑ ❑
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water (Y p ❑
distriburion facilities installed on or after 7uly 1, 1988.
(5) No solder or flux which eontains more than 0.2% lead exists in private water �''� ❑ ❑
di�tribution facilities installed on or after July 1, 1988.
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Water service shall not be provided or restored to the private water distribution facilities until the 9�ove coadirioas are determined to be
in compliance.
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I certify that the following materials will be used in the instailation of the private water distribution facilities located at `
and that the inspector wi�l validate compliance during the i�spection process:
Service lines Lead ❑ Copper 0��/ PVC ' ❑ Other $�''�� ,
der Lead ❑ Lead Free t� Solvent Weld 0 Other �'`�^ `. «
' I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validiry of the information I have providcd.
,
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nature of Licen d Plumber Registration Number
� YYI � � -t�/ _/�
Type of Registration Date
I recognize that this document shall becofie a permanent record of the aforementioned Public Water System and that I am legally
respo' sible for the validiry of the information provided.
, �J-�,z � � �.� !��
' at'ure of Inspector Registration Number -
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Type�of Registration , Date
:�:_ •
White•Customers Copy Yellow•Ciry's Copy Pink-[ospcaors Copy
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