556 Heritage Oak (2)CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOr
Residential O Commercial TNRCC ID#0570040
I_
e a _ upon inspection of the private water distribution facilities located at
5-- S—i ,,– , j.which 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 Compliance
1) No direct connection between the public drinking water supply and a potential
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 O
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov
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 CY
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 p'
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 CY p
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities until the above conditions are determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water disuibution faciliries located at
S", \i .. -a _and that the inspector will validate compliance during the inspecrion process:
Service lines Lead Copper PVC Other
Solder Lead Lead Free Solvent Weld Other C/
I recognize that this ocument shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for e idity of ation I have provided.
G L\
Signa re of Licensed Plumber Regish ation Num er
q t 1 r
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 validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Customers Copy Yellow•Ciry's Copy Pink-Iaspectors Copy