501 Bethel SchoolCITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTION
Residential Commercial TNRCC ID#0570040
I 7 f ' upon inspection of the private water distribution facilities located at
3Z 1 1`e 1 SC 2 , which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non-N/A
Compliance Compliance
1) No direct connection between the public drinking water supply and a potential p
source of contamination exists. Potenrial 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 LY
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
prevention 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 p' p p
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 Td
disuibution facilities installed on or after July l, 1988.
5) No solder or flux which contains more than 0.2% lead exists in private water p
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water dis ibution facilities unril the above condirions are detemuned to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution faciliries located at
3''"'` S— . and that the inspector will validate compliance during the inspecrion process:
ervice lines Lead Copper O PVC Other C3"
o der Lead Lead Free Solvent Weld Other
I recognize that this document hall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity the information I have provided.
y a `
Signature of Licensed Plumber Registration Number
c r,h o'.,, c,r-13
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
responsible for the valid' f the information provided.
C" y 2 `
Signature of Inspector Registration Number
sl v q'"!r., o w l/r-/ f
t
vpe of Registra ion Date
ite-Customefs Copy Yellow-City's Copy Pink-lospeaars Copy