762 Cameron CtCITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOn
Residential L'J Commercial TNRCC ID#0570040
upon inspection of the private water distribution facilities located atIF..,b; ! c!—
p, ,y,r which is connected to the City of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non-N/A
Complian e Compliance
1) No direct connection between the public drinking water supply and a potential
source of contamination exists. Potenrial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
2) No cross-connection between the public drinking water supply and a private water
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflow
prevention assembly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
3) No connecrion exists which would allow the return of water used for condensing D
cooling or industrial processes back to the public water supply.
4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water
distriburion facilities installed on or after July 1, 1988.
5) No solder or flux which contains more than 0.2% lead exists in private water
dis iburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities until the above condirions are detemuned to be
in compliance.
I certify that the following materials will be used in the installation of the private water distribution faciliries located at
o ,wt r and that the inspector will validate compliance during the inspecrion process:
Service lines Lead Copper PVC Other L9'
Solder Lead Lead Free f Solvent Weld Other
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information I have provided.
v 1- 9
nature of Licensed Plumber Registration Number
I PS 1° —z —
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
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Signature of Inspector Registration Number
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Type ofRegistration Date
White-Customers Copy Yellow-City's Copy Pink-Inspectors Copy