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CLT�'�ON�ER�ERVICE.frfSPEC�'7,01'+� �
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Residential [�Y' Commcrc�al C7 'I'PIRCC ID�F057b04D �
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- /� upo�it�specfion of th�griti�atE water dishibUtinb faGilities loca�ed et : � �
_ wbzch is cannected tn the City ot Coppell Watcr 5ystem,do hereby cez#ify
: that,to the best of my knowTedge: �
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Tn Nori- T�ttA �
�omgli _anes Corr�jiance ;`;
(I)� No direct connecrian bet�v.aen the public drinkiug water suppIy and a potantiat �'J/ ' � �] '�:
source of contaznination exisis. Potentiu�souxces af cozttnmination are isolated ' ' F
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froxn th�public v,�ater systern by au air�ap or an appropriafe backfIow grevention �'
assembFy in accordance with Co�nrission regulations. , r
(2) Na crnss-connectionbekween thegubIic drznking water suppiy aud a privaie vrater � � D
system exists;li�irera an ac4a,i1 airgap is notmaintained batvrecn ttie�ublic wateX
snpply and pzivate vvater snpply, an approved reduced pressnre zgue backE�ow� ' %
, reventioit asscmbl �
p y is proparly instalied and a ssryice agreement nxists for
annuat inspeotio�and#esfing bq a ce�ed back#laiv prevenkion device tester: �
(3) No connecdon exisis which would aIlow tha retnrn of water used foz candensin� � p �
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; ooaI'mg or indusiria}grocesses back ta fha public waeer'supply, �
{4) Na pipe arpipe firiing wbich oorrtains more than 8,0%tead exisfs iA private watez �- p d �
distrihudan facilities instaIled an or aftex•]'uIy I,1988. �'
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{S) No soidar oc fiux vr#ich confains more tharz 0,2% lead exists in�srivaf� water �p • p ;
distn'bukion facil{ties installed na or after 7uly 1,I�88, r:
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Water service shall natbe prpvided or restored ta fhe private wat�r distribuiian facilities until the above eanditions are deter�rzined io be
irz compliatzca.
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1 ccr.ti£y that the follo�•9ng materials�vi1l 6e used in the installation of the privace wa#ez dism'bu�ion faciiities I6cated at
`J' 2 3 e�b`/ aad that the inspector wi1�vajidute comp}iaaee d�rcng the znspection proeess;
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ervica tiaes Lead 17 Copper t7 PVC ' Ci Ottier � "j
Solder Lead L7 L.ead Frea � Solve�k W�d [J Otber ❑ �
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I rec�gnize tharthis docvment shaTl iiecome a pe,rmane,nf recozti3 of the aforementioned Publi�Water Sysicm and that I atn IegalIy �
responsz�h��for the validity of the ixiformadon T have provided.
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Sxgttatur S.ice' Ztegis�aiiv.�NumbeF �
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Type of R.egislrafiou . . �
Date
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Y recoguize that•this doctunent shall become a permancnt recoxd of.the aForcmeationed�'o,bli��a#ex System and fiha#Z am tegally f
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r�spony�ijSIe fo e validity ofnc�infarmafion ' d,
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Signa[ure q it�vector Registraho�a Nuinber / �
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Date
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Wbi¢-Customctr CUPY YcEIOW•Cit�s Cnpy Pirik-/nsACqa�SCoAY