2016_1103 CITY OF COPPELL WATER UTILTTIES
CUSTOMER SERVICE INSPECTIOIti
Residential � Commercial ❑ TNRCC ID�t0570040
I � ( ' ,upon inspection of the private water distriburion facilities located at
, which is connected to the City of Coppell Water System, do hereby cenify
that,to the best of my knowlcdge:
In Non- N/A
Compliance Compliance
(1) No direct connecrion between ihe 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 prevention
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking waier supply and a private water I� D �
system exists. Where an actnal air gap is not maintained between the public water
supply and private watcr supply, an approved reduced pressure-zone backflov��
prevention assembly is properly installed and a service agreement exists for
annual inspection and testiag by a certified backflow prevention device tester.
(3� No connection exists which would allow the return of water used for condensing � p ❑
cooling or indnstrial processes back to the public water supply.
(4) _ No pipe or pige fitting which contains more than 8.0°/a lead exists in private water � ❑ ❑
dis�ibution faciiities installed on or after July 1, 1988.
(5) No solder oz flux which contains more than 0.2% lead exists in private water � ❑ p
distnbution facilities instaticd on or after 3uly 1, 1988.
Water service shall not be provided or restored to the private water distribution facilities until the above conditions aze determined to be
in compliance.
I certify thai the follo ' g enals will be use in the installation of the private water distribvrion facilities located at
� and that the inspector will validate compliance during the inspecrion process:
Service lines Lead O Copper C7 PVC ❑ Other � '`'�"
Solder Lead ❑ Lead Free � Solvent Weld � Other L7
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I ain legally
re ible for the validity of the informatio I have provided.
: t..� � �
Sig ture of Licensed Plumber Regis�ation Number
� � s ��� �" � ��
Type of Registrarion Date
I recognize that this document shall become a permanent record of the aforemenrioned Public Water System and that I am legally
res ible for the validity of the infom�atio rovid .
� �a �? � `7
Si n Inspector Registration Number
� �� - I
Type of Registrarion Date
Wbit�_C�rs Copy Yellow-Ciry's Copy Pink-laspeaors Copy