2016_0914 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTI01�
Residential C�' Commercial ❑ TNRCC ID#0570040
I v ""'� �J � �Q�2 �f'� ,upon inspection of the private water distribution facilities located at
73� �.fwrnr.•or,a� , which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compli e Compliance
(1) No direct connection between the public drinking water supply and a potential � O ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection between the public drinking water supply and a private water C� ❑ ❑
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflo��
prevenrion assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing C� ❑ ❑
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 C� ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water � � ❑
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities unril the above conditions aze determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water disti-ibution facilities located at
and that the inspector will validate compliance during the inspection process:
Service lines Lead O Copper ❑ PVC � Other �
Solder Lead D Lead Free �� Solvent Weld ❑ 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 validity of the information I have provided.
l�- 9'z �3
ature of Licensed Plumber Registration Numbec
R m � q-iy-I�
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
respo sible for the idity of the information provided.
rIj—q z�3 w�s P—s
' ature of Inspector Registration Number
R rr� �' �i.s�°s 9-�y/u
Type of Registration Date
White-Customers Copy Yellow-City's Copy Pink-Inspeaors Copy