131 Trinity CtResidsutial Commercial I:ti'RCC ID it05700 0
1 upon uupe;tioa uf die pn.a e wa u disoribution facilities Ic ca d at
which is connected t thr C'in•of Coppell Water System do 6enbvi certify
that,to the bat of my lmowledge:
ln lon-A
Comp2iaac Compliaace
1) No direct :onnec5oa berx•cen the public driakiag aater supply aad a potens:a'. p p
source of contamiaa on cxisu. Potential sources of contaminaaon ;se isolaud
Erom tt e public watu sysiem by an air gap or aa appropriaic baclilou prc•cntioa
assembly in acco daace w t6 C.u uiission reguiatioos.
2) No aoss-connecuon bctween the public drinking water supply aud a privat wata O u
system taists. Wherc an sctual air gap s nw maintained between the pubiic watcr
su ply and pnvau wster su ply, m approved reduced pressure-zone backflow
prcveation assernbly u properfy mso lled a a semce agretment cxut5 for
anaual iaspeeuon and test ag by a ctrofied bacicflow prcvenhon dev ce tester.
3) No coonection exists which would aUow the retutn of water used for condensing Q p
cooling or industrial processes back to the public water supply.
4) No pipe ar pipe fitting whicb contains more than 8.0%lead exists in private water p
distnbution facilities instalitd on or after Julv 1. 1988.
5 No solder or flux which c ntains rtx rc than 02° lead exists in omate water 0 p
distr bution facilitie install d on c r aRrr Julv 1 19RR
Wata sen ice sball not be proti7ded or rtstorcd to the prisatt 4•a!r. +is*i utie tacilit cs:ti!the aM e:ondi+o se de!cimined to bc
ia compliancc.
I certify that iLe follow g materul, ill be us;d iu the iusiillition of thc pri ate kater discib;t;on.atLities 1oau3 ai
1 ( and that the inspector will validate compiiance durmg the inspection pr+ocess
Ssrv ce luus Lead D Copper u r Vt, u t)tner S- /E
Solder Lead O Lad Free 0 Solvent 1A etd Other y
I recogaiu that this document shaU become a perrrnnrnt raord of the aforementioned Public Water System and tbat I am legally
r bk for tLe validiry ofthe informaaon 1 haye provided.
7 r -7
fL. --_ C_ !_ --
Sig re of Licensed Plum Reeistration NumF+er
itiit 31- 1(
Type oCRegistration iia r
I recogaue that thrs docuaxnt shaU become a parnanent record oi Ct e afonmennoned Wouc Water ystem and that 1 un legaliy
s'at ble for tbe wl ry ot the mformaaoa rov dS,A.
I 4
S gn re of Inspector Registration Number
3 — Ic
Typc of Regis aton Da;;,
W 1r•Qweqlert Caov ye rr.Cm a l''.t. vinl-e.Me+n.s rrq..