633 CanterburyC TY OF CQPPELL WATER UTILITIES
CUSTOMER SERVICE.I`SPECTI.UIti
Residential Commercia! TNRCC ID#U574U4Q
I a " `u .n ins ection of thepop pnvate water dish-but on facihnes located ac
L C19'V'I Cr' 'jc (`.f tivhich is coaneaied tQ the Cxty of Coppell Water System,do hereby certify
that,ta the best ofmy k.nowledge:
1*1an- N1.A
Compliance Compliance
1) No direct con eotian between the public drinking water supply and a potential
saurce of contamination exists. Potential sanr es af cont emiaa ion sue so]ated
fram the public water system by au air gap or an apgrnpriate backflow prevention
assemhly in accordance with Cotrunission regulatians.
2) No cross-connecEion b tween the pul tic clrinkuig water sugply and a private water ` [ p p
system exists. tiVhere an accual ai gap is not maintained.ba.tween the publia water
sapply and private water supply, an approved rednced gressiireraone bacicflow
preventiou assembly is properly instalied and a service agreement exists for
annnal iuspec#ion.and testing by a certi ed backflaw prevention device tester:
3) N connection exists which would allow thc return of water used for condensin
oqTiz g or industrial processes back ta t e public water supply,
4) No pipa or gipe fitting which contains more than 8,0°JQ lead exisis in pri ate water p p
distribution facilities installed on ar after.7ul}I,1988.
5) No solder or tlux w3 ich cantains mare than 0.2°/a lead e+cists in private water p • . p
distribution facilities installed on or after July 1,1988.
Water service shall not be provided or restored to tbe private ater distrihution facilities until the above eandition are dctenmitaed to beincvrnpliance.
I certify that the fallawing materials wi11 be used in the installatian of[he.priv Ee water distribution f.acilities 16cated at
and that the inspectpr wili vaiidate compliance during the inspectia process:
Seivice lines Lead Cogper PVC t Q r
Solder ead CI ad FzQa '` Snlvent Weld DClier T 1y..
I recn nize that this dacument shall become a permanent record of the aforemention d Fut lit Water Systcm and tl at I am l gallyresponsibforchevalidityoftheinformationIhaveprovided.
Signature ofT.ice d Plumber Re isi=atj ,Numbe
Typa ofRegistrafion D te
recognize that•this document shall become a permanent record of.thc aForementioned Public Water System and fhat I am legallyrespon " ie for the vglidity of the infonrcati n provided.
Signature of pector R istratio Number
Typa fRegistration Da— t
u'hitc-Customers Cupy Ye Iaw.CitY.s Co y Pink-InspCClofs Copy