625 CanterburyCITY OF CQPPELL WAT R UTILITIES
CiJSTOMER SERVICE fNSPECTI01`
Residential [," CommesciaM TI IRCC ID#057004I`
I r •s``u on ins ecti o e p'x wat r dsstxiLution facilitiss lacaccd at
t'"f which is connecied to the City of Coppell WaTer System,do hereby ceztify
that,to the hest of my knowledge:
Tn Non- NIA
CampIiancs CornplianceI Na d rect camaection beriueen t e gublia drinking wat r supply and a patentiai Qsourceofcantami.aation exisrs. Pofential sources af contarninatian are isolated
from the public water system by an air gag or an apgrogriate baekfIow greue tion
asse nbly in accordance with Co zmission regula ons.
Z} No crQss-connectian betwcen the pubiic drinkizzg water suppiy azzd a privai vvater ' Cs" p psystemexists,Jhere an actual air gap is nat maintained betvreen the public water
supply and private water supply, au approved reduced pressure-zone h ekf ow
prevention assembly is proparly instafled and a s rvice agreement exists for
annual inspectionand testing by a certi ed ackflotiv prevention device tester.
3} t Fo cnnnecrian e}cisis uJhicfi wnuld a low tlie retum af vater used£oz condensing p
cooT g or'sndus al processes back t the public water suppiy.
4) No pipe orpzpe fitting v rb,ich contains mare than 8,Q°!a lead exists ix private water p
disiziburian facilities installed an or aft r.July I, 1 88.
Na solder or flux w ich cont.ains more than .2°/a lead exzsis in pri ate water C/ p pdistrz'burion f cilities inst ed on or after July I,1 88.
Y•'
Water service sha11 nat be pmvided or restored to the private water distribuCion facili,des unti,l the above ennditi.ons are deta znined to beiucompliancc.
I certify that the fallawing materials wifl6e used in the installati m of the grivace vvatez d sm'bu#zon facilities lr5cated at
f^-tw,y aud that the inspector will validate compliance dtuiug the inspectian process;
Service Iines Lead Cogpec PVC p r
QF Lead X.ead Frcc '' Soivsnt Weld O Other Llk."
T recggnize that this document shail become a pezmazseni rc ord of the aforementioned Pt blic Water System an3 that I axn IegallyresponszbforthevalitlityoftheinfomxationIhaveprnvided.
Signature ofLice d Plumber Re ist ation N'um.be1:P.
Type af Registrarion Date
I recognize that•this docu i;ent shatI e ome a pecmanen.t zecord of the aferementianed Public Water System aad Ehat I am legallyrspon ' ie for the validity ofthe infaiznabon provi$ad.
Signa[are ofZ pectar RegisGalion Number
d i Type ofRe is-atien Date
1Vhia-Cus[amers Coyy YtElOw-Cit.S Capy Pinlc-[asPecfofs CaAY