2016_0914 � � � ` ��
� CITY OF COPPELL WATER UTILITIES '
CUSTOMER SERVICE INSPECTI01�
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Residential Commercial � TNRCC ID#0570040
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,ur�n u�►srect��n�f the pm�ate water listnbution facilities located at
%��,� f-�.,w,,,,,��,rl ,whieh is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compli e Comgliance
(1) No direct connection between the public drinlcing water supply and a potential � ❑ ❑
source of contaminarion 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 regularions.
(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 approved reduced pressure-zone backflow
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 return of water used for condensing I,� ❑ ❑
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 Cf ❑ ❑ , .�
distriburion facilities installed on or after July 1, 1988.
(�) No solder or flux which contains more than 0.2% lead exists in private water C� ❑ ❑ � �
distriburion facilities installed on or after July 1, 1988.
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Water service shall not be provided or r"estored to the private water distribution faciliries unril the above condirions aze detemvned to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion faciliries located at
and that the inspector will validate compliance during ti}�pection process:
'� Service lines Lead ❑ Copper ❑ PVC ❑ Other C�'�r
Solder Lead ❑ . Lead Free � Solvent Weld ❑ Other C3'�'��
I recognize that this document shall become a permaneat record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
_ .
�J-�273
S` ture of Licensed Plumber Registration Number
� Y�'� r� 9—�E�—��
Type of Registrarion - Date
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 provided. `� .
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S � �.._
ature of Inspector Registration Number
IQ I�l') � G�/S f°-s" �1_/y-/�
Type of Registration Date
White-Customels CoPY Yellow.City's CoPY Pink-Inspectors CoPY