744 Hammond t � CITY OF COPPELL WATER UTILITIES
" , ""' � . � CUSTOMER SERVICE I1�SPECTIOT , S
� Residential [8" Commercial ❑ TNRCC ID#0570040
� I � ta_� � ��rF f r� �?`' �
,upon inspection of the private water distribution facilities located at
7t.��� j-?�; ,,., i.,,;c;r��a' ,which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my knowledge:
In Non- N/A
Compli �e Compliance
(i) No direct connection between the public drinking water supply and a potential � ❑ ❑
source of contaminarion exists. Potential sources of contaminarion are isolated
from the public water system by an air gap or an appropriate backflow prevenrion
assembly in accordance with Commission regulations.
/
(2) No cross-connection between the public drinking water supply and a private water G�'l p p
system exists. Where an actual air gap is not maintained between the public water
supply and private water supply, an approved reduced pressure-zone backflov��
prevenrion assembly is properly installed and a service agreement exists for
az�nual inspection and testing by a certified backflow prevention device tester.
(3) No connecrion exists wluch would allow the return of water used for condensing fia'' 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 private water � p ❑
distribution facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private water [�� p ❑
distribution 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 determined to be
in compliance.
I certify that the following materials will be used in the installarion of the private water distriburion facilities located at
and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper 0 PVC ❑ Other L3'��_,,--
Sol er Lead ❑ Lead Free � Solvent Weld ❑ Other 0'��
I recognize that this document shall become a peimanent record of the aforementioned Public Water System and that I am legally
responsible for th__e�validity of the information I have provided.
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gnature of Licensed Plumber Registration Number
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,
Type of Registration Date
I recognize that this document shall become a permanent record of the aforemenrioned Public Water System and that I am legally
responsible for the validity of the informarion provided.
,__,
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� �Irat�e of�Inspector Registration Number
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Type of Registration ^ Date
While-Customers CoPY Yellow-City's CoPY Pink-Inspeqors CoPY