2017_0426 CITY OF COPPELL WATER UTILITIES
CUSTOMER SERVICE INSPECTI01�
Residenteal f� Commercial ❑ TNRCC ID#OS70040
I � �..}� G � � �t!k C� ,upon inspeciion of the private water disti-ibution facilities located at
�C7� � [��_,P� , which is connected to the Ciry of CoppeIl Water System, do hereby ceriify
that,to the best of my knowledge: �
In Non- N/A
Compliance Compliance
{1) No direct connection between the public dtinking water supply and a potential �' ❑ p
source of contaminarion exists. Potential souzces of contamination are isolated
from the public waier system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regularions.
(2) No cross-connection between the public drinking water supply and a private water � ❑ p
system exists. Where an actual air gap is not mainiained between the public water
supply and private water suppIy, an approved reduced gressure-zone backflov��
prevention assembly is propetly installed and a service agreement exists for
annual inspection and testing by a certified backflow prevenrion device tester.
{3} No connection exists which would allow the return of water used for condensing � p p
cooling or industrial processes back to the public water supply.
{4) No pige or pipe fitting which contains more than 8.0%lead exists in private water � ❑ p
dis�-iburion faciliries instalied on or after July 1, 19$8.
(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 distributian faciliries until the above conditions are determined to be
in compiiance.
I certify that the following materials will be used in ti�e installarion of the private water dismburion facilities located at
3� �X t2c� �.� and that the inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper (� PVC ❑ Otlier �- r��`'
Solder Lead O Lead Free ❑ Solvent Weld ❑ Other �
I recagnize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
res ible for the validiry of the infom�ation i ve provided.
: -� 3 t�O � '7
Signa re of Licensed Flumber Regisuation NumbeF
l-�Vl�``� � �— �-�ry - (�
Type of Registration Daie
I recognize that this documeni shall become a permanent record of the aforementioned Public Water System and that I am Iegally
respo ' le for the validity of the informati provi d.
��
_' t ft�� '�— L.J � ��� � �
Signa e of Inspector Regis�ation Number
� ��5 � � a�: - c �
Typc of Regis�a ion Date
�'�dtic•Custotoet's Copy Yollow-Ciry'a CoPY Pink-laspeaora CoPY