120 Rosebriar (2)Reskdrnti l Camrnercf9l TNRCC 1q tOS70040
J Tl " upot iaspection of t e nvate wata dis ribution faeilidea located a
j G l G.L ' 2f4,which is counectcd to the City af Coppell W tsr Systcrr c3o hcrcby certity
ci et,to thc best of my k wied:
ln Nan•N/A
Co ance Compliaace
t) ldo dircct co ncdion betwcta the public dri tki g water su ly ae a patentia l Q p
source of cantamir ation txists. Poteritie3 saurc s of contamination are isolated
frorn the pubtic wateE y trm b3 sn.ir gap ar u ap opriste backflow preventioa
asacmb tu sctard nct with Commissiot egut tic s.
2) No cross-can c ian bttwccn tht pubtic dfinkiu w ter wpply and a privsle waoer p p
aystem exats_ Wherz n utwl au gs i aot mt{mmined b tween the publit wetar
supply and priv t wittr suppJy, Ai1 p[Ovtd redutCd preSSllnG-zo e beckflav
pr vaits assembly i: praperiy ir stzlled and en+ice agreanent cxists fvr
annual ivaspcction and teating by s cerrificd backilow prevcation device kstrr,
3) No conaeckion exiats wls ch woul a[taw tha red rn of wstcr tiscd tor carudcasi O O
coofi or ind strial pto csses back to the public wsteT supply.
4} No pipc or pipe fi ing wbich conrains Morc th a 8.0°61e d exists i private water p
distributi fa iliti,ees ins lted on ar after IU y 1 1988.
5) No soldtr c r fltuc which conisins mare th n 4.3% lcad exists in pnvate watrc Q p
distri tion ficiliti s ia talkd o or sftu July 1, !9$8.
Water scrvue sh ll nat be pravidtd or res ored to t+e priv te water distribution f cil ties uacif the abo e caadidoas ue dctcrmir ed to i
ia car liss cc.
I c.crtify that the followiug msteriels witl be wed in the i atallatiaa ofdse privat wetcr dia tibuti+n fae;titizs bcated t
K-t f2 A IZ nd lhet the inapectot will v'lidate compliwce dwiag the insptct;an ptoces
ee*•• , Lead 17 Copper P C th6er D
Lead C Ltad Free Solvent Wald O Other O
1 re agniu rhvt ihis documeRt sha11 bccamc a pecmtnent recotd of the foremtn iancd Publit W4ter Systtm and t'hst T Ym kgally
respe for tJu vZlidity of fcrrmation t hsve prov;ded.
Sign re of'Lxcen ed P mber Regisaac;an Namber
Q '`- Ltit1LC'1LS
I'rpc of Registratian Date
1 reta ize that lhis document sha11 become e p+nsnent tcor+d of the aforementior e Pubtic Water Systern aad th t (m kgally
rtspansiblt for the v3Zidity of the ulfonn tion prvv;dcd,
Signature of Inspectrnr Rcgistretioe Nurnbcr