610 WesthavenCITY OF CCIPPELL WATER UTILITIES
CUSTQMER SERVICE NSPECT10Pv
Residential Cnmmercial TNRCC ID#0570Ud4
r 1 upon ins'ection f the private water distribution facilicics located at
wh ch is connecied to She City of Coppelt Water System, do hereby certify
that,co the besf of my knowledge:
In Non- A!!A
Compliance Complianee
1) Na direct con ectian between tbe public drinking water supply and a potential
saurce of contamination exists. Potential sources of contamination are isolated
from the public water systern by an air gap or an appropriate backflow prevention
assembly in accordance with Conunission regulations.
Z} No cross-coruiection between the pubtic drinking water sugply and a private water f'' p p
system exists. Where an actual au gap is not maintained between the publia water
suppIy and private water supply, an approved reduced pressurc-zone hackflow
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certifed backflQw prevention device tes#er.
3) I*10 connecrion exists which would allow the retum of water used for condensin y` p
cooling ar indus ial processes back to the public water supply,
4) Na pipe ar pipe fitting which contains more than 8A% lead exists tn pri ate water p p
distribution facilities installed on or after 7uly I,1988.
5) No solder or tlux w ich contains more than 4.2°/a lead exists in private water
dis ibution facilities installed on or after 7uly 1,1988.
Water sarvice shaIl not be provided or restnred to the private wa[er dislribution facilities until the above conditious are determined ta beincomgliance.
F
I certify that the fallowing materials will be used 'zn the installation of the private water distribution facilities Iticated at
r,/o Gl/EsYy,QVE and that the inspector will validate compliance during the inspectian process:
Scrvice lines Lead Copper FVC Qther [
Solder Lead J.ead Free ` Solvent W ld Q Other
I recognize that this document shall became a permanent record of the aforementioncd Fublir Water System and that I am legally
responsib for the validity of the information I have provided.
Signature of Lice d Plumber Regis ation Numberk.P q-,
Type ofRe istration Date
I recognize that•this d ctunent shall hecome a permanent record af the afarementioned Public Water System and that I am legally
respon ' le for the validity of the infoanation provided.
Signature of I pector Registration Number
1_ S s -"
Type ofRegistration IIate
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