746 Hammond CITY OF COPPELL WATER UTILITIES ��� �
� .� ' CUSTOMER SERVICE INSPECTION . +,� ,
.k
Residential Commercial ❑ TNRCC ID#0570040
I .� '� �' �J� ✓-�'� � '�� ,upon inspection of the pm�ate water distribution faciliries located at
;'�;� �< -.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
Compli ce Compliance
(1) No direct connection between the public drinking water supply and a potenrial � � ❑
source of contaminarion exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking water supply and a private water Q� ❑ ❑
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 inspecrion and testing by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retum of water used for condensing fd ❑ p
cooling or indusuial processes back to the public water supply.
(4) No pipe or pipe fitting which contains more than 8.0%lead exists in private water � ❑ ❑
distribution faciliries installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water � ❑ ❑
distriburion 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 conditions are determined to be
in compliance.
I certify that the following materials will be used in the installation of the private water dis�ibution facilities located at
and that the inspector will validate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead � Lead Free �' Solvent Weld 0 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.
�`�.�- ��- ;� �
'gnature of Licensed Plumber Registration Number
i
f r�'7�'
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
re o�cable for the validity of the information provided.
�____-------
/�'I- �,2. � .� G�/S �'S"
nature of Inspector Registration Number
R ��1� ��ss�.�
Type of Registration Date
White-Cuuomers Copy Yellow-Ciry's Copy Pinlc-Inspeaors Copy