631 WesthavenCITY OF CQPFELL WATER UTILITIES
USTOMER SERVICE'NSPECTIUI
Residential Commerciat TNRCC ID#0570040
j f `- / ' f r f '`/ ugon inspectian of the private water distri6u#ion facilities ]ocated at
0 3 11 l l CN which is connecied to the City of Coppell Water System, do hereby certify
that,to the besk of my knowledge;
In Non- T'JlA
Compliance Compliance
1) No direct connection between the publio drinking water supply and a potential p
saurce af contamirtation exists. Potential saurees af cantumination are iso]ated
from the public water system by an air gap or an appropriatc backflow prevention
assembty in accordance with Commission regulations.
Z) No cross-connection between th put{ic drinking water supgly and a privaIe water p p
system exists. Where an actual aiz gap is not maintained between the public water
supply und private water supply, an approved reduced pressure-zpne backflow
prevention assembly is properly installed and a servicc agreement exists far
annual inspection and testing hy a certifed backflow prevention device tester.
3) I 10 connection exists which would allow the return of water used for condeasin y' p
cooling ot'indus ial processes back to the public vater supply,
4) No pige or pipe fitting wh ch cantains more than 8.0°0 lead exists in private water O O
distribution facilities installed on or after duly 1, 1988.
5) No solder or fiux which contains more than 0.2°la lead exists in private water
distribution facilities installed an or after]uly 1, 1988.
Water service shaIl nnt be provided or restnred to the private water distribution facilities until the above eondiri.ons are dCtermi ed to be
in complianee.
I certify that the fallawing materials will be used in the installation of fhe priva[e water distribution facilities ItScated at
and that the inspector will validate comptianee during the inspection process:
Service lines Lead Copper PVC Qther i[
Solder Lead Ct J ad Free J` Solvent Weld Other
I recognize that this dn ument shall becvme a permaneni recard of the aforementioned Fuhlic Water System and that I am legallyresponsibforthevalidityoftheinformutionIhaveprovided.
Signature flf Lice d Plumber Registrati' n NumheFk;,s
Type of Registration D te
I recoguize that this document sha11 became a pem anent record of the aCorementioned Public Water System and that I am legally
respon ' ie for the validity af the infoczriation provided.
r
Signatur i ector Regis atio Number
Type of Registration Daie
N'hilt-Customeft Cupy Yellow-Citys Cnpy Pink-laspcnafr Copy