614 WesthavenCITY OF COpPLLI.WAT R UTILITIES
CUSTOMER SERYICE NSPECTIOlti
Residentiai [" Commereia! TPIRCC ID#05743040F`
I upan inspectiQn afthe prn ate water distribniion facilitiss lncated ac
Sfh sf. 'which is connecied to the Ciry oi'Coppell Water System,do hereby certify
that,to the bcst ofmy knowled e:
In Non- NIA
nmpliance ComplianceljNodxzectcauiaectionbetveenthepublicdrinlcingwazersupplyandapotentiaifQ p
source of contaminatioa exisu. Pofent al svttzc s af coutuminatinn are isolated
fram the public water system by au air gap or an apgmpriate backtivw preveestion
assemhfy in accordance with amtrcission regula ans.
2} No cr ss-connectian betweea the pubIic drirk,n_o water suppiy azid a privaie water Ct p psystemexists,ti fsere an actuaI air gap is not maintained betvr$ea the pubSic watcr
suppIy and privaTe v ater sv,pply, an appro ved reduced pressurc-zqme b ckflow
preventian assembly is properly installed and a s rvice agreement exists for
annual iuspeetionand testing by a certifed hack#l4w prevention device tester:
3) No cnnnectian exists tyhich would aIlaw the return ofwater used for cnndeusing p DcooImgoriadusi.al processas back ta the public water st pply,
4) Na pipe orpipe fitting vv,ich contaizis more[han 8,0%lead exisfs in private watez p 0disibuaonfaciIitiesinstalledonorafterdulyI, 1988.
5) Na salder or filux v3 ich eoniains more tfian 4.2°/a lead exists in private vater g,/ pcEishutionfacilitirsinstal]ed on orafter July 1,I938.
Water service shaIl not he provided or restored Ya the private water distxibution fac iries un[il the above eandetions are detennined ta beincompliance.
I ceztify that tUe a114-ing materials wiIi be used ia tile insfallatian of the.g.rivate water d smbut on facilities Ibcated at
C/ uC t 2 ie•, aud that the inspector wiIl validate oFnpliance d ug the inspecrian process:
Servrce[iFees Lead O Copper PVC Otlier Solder T.ead I.ead Fre 'Solvent Weld Cf Other a
T recoo;,e that this document shall become a permaneni recard of the aforementioned Publir Water System and that I am IegallyresponsibforthevaIidityoftheinformationIhaveprovided.
j G
Si ature af T,ice d Plumber Registtration NumSer
P y/ J z,Ty}se ofRe isirarion Bat
1'recogztize tliat•this document shalI beoome a pecmanent record ofthe aFflremeurioned.PabLie Watez System aud tlsat I azn legalIyrespon ' le far tfie validity af the infarmabon provided.
Signature o'I pector Re istration N tmber
S fLfTygeoFRegis-ation Date
S5'hiu-Cns amcrs Cupy YallOw-Cit s Copy pinlc.[piptdofs Cnpy