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CITY QF COPPELL WATER UTILITIES
CUSTOMER SE'IrVYC'E INSPECTIOr
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Residential C Co 'mmercial R D#0570040
I _;c: . . ?'G-k r.:"a' upon inspection of the pribate water distribution facilities located at
C' ' . ,-.I rn/ which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non-N/A
Compliance Compliance
1) No direct connection between the public drinking water supply and a potential Q Q.F<
source of contamination exists. Potenrial sources of contam nation .are isolated
from the public water systern by an air gap or an appropriate backf ow preventi ti '
assembly in accordance with Commission regularions.
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 ass nbly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
ti,;
3) No connecrion exists which would allow the retum of water used for condensing p
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 pnvate water a'
distriburion faciliries installed on or after July 1, 1988.
5) No solder or flux which contains more than 0.2% lead exists in private water C Q
distriburion facilities installed on or after July 1, 1988.
Water service shall not be provided or restored to the private water distribution faciliries until the above condirions are detemuned to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion faciliries located at
7b '. tttt I! ('e:,+EtL, Tr and that the inspector will validate compliance during the inspecrion process: '
Service lines Lead Copper PVC Other LR
ySolder Lead Lead Free C"'Solvent Weld O Other
r I recognize that this doeument shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity ofthe information I have provided.
3 3'
Sig re ofLicensed Plumber Registration Number
rr "* r4' ,r,s.f.•,,"c 1','`,,;i r,a rFr r
Type of Registrarion 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 informarion provided.
Signature of Inspector Registration Number
Type of Registration Date
White'.-Customers CoPY`" Yelbw-Ciry's CoPY Pink-Inspeaors CopY
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