2017_0606 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTIOT
Residentiai � Commercial Cl TNRCC ID#0570040
I ��11�ItJ l �. � l7 ((�L t�. ,upon inspection of tl�e pri��ate water dis�ibution facilities located at
��O �pU fl n.� ,which is connected to the Ciry of Coppell Water System, do hereby certify
that,to the best of my Imowledge: �
In Non- N/A
Compliance Compliance
(1) No direct connection betwecn the public drinking water supply and a potential `� ❑ O
source of contamination 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 C� 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 backflou�
prevention assembly is groperly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevention device tester.
(3) No connection 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 exisis in private water `� p p
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 � ❑ ❑
distribution faciliries installed on or after July 1, 1988.
Water service shall not be provided or restored to ihe private water distribution facilities until the above conditions aze determined to be
in compliance.
I certify ihat the fallowing materials will be used in the installation of the private water distribution facilities located at
_� � S r )�'\1 D r� and that the inspector will validate compliance during the inspection process:
Service lines Lead � Copper ❑ PVC ❑ Ottier (� P�'�
SQlder Lead ❑ Lead Free ❑ Solvent WeId ❑ Other �
I recognize that this document shall became a permanent record of the aforementioned Public Water System and that I am legally
re sible for the validity of the information I have provided.
- �-� �C�� �'7
SFgn re of Licensed Plumber Registration Number �
�-`�'` � C�- �- l�7
Type of Registrarion Date
I recognize that this document shall become a permaneni record of the aforementioned Public Water System and that T am legally
resp 'ble for the validity of the information provided.
� �- �� a� q
Signa e of Inspector Registration Number
�s p S (�-G�� [�
Type of Reg stration Date
White-Customets CopY 1'etlow-Citys CopY Pink-taspcctofs CapY