1234LakeshoreDr#300_75019_16154Texas Commission on Environmental Quality
Customer Service Inspection Certificate
Name of PWS Coppell PWS I.D.# 0570040
Location of Service 1234 Lakeshore Dr #300 Coppell TX 75019
Reason for Inspection: New Construction
Existing service where contaminant hazards are suspected
Major renovation,correction or expansion of distribution facilities
Re-Inspection
I Scott Masdon ,upon inspection of the private water distribution facilities connected to the aforementioned public water supply
do hereby certify that,to the best of my knowledge:
Compliance Non
Compliance
(1)
No direct or indirect connection between the public drinking water supply and a potentialsourceofcontaminationexists.Potential sources of contamination are isolated from thepublicwatersystembyanairgaporanappropriatebackflowpreventionassemblyin
accordance with Commission regulations.
(2)
No cross-connection between the public drinking water supply and a private water system
exists.Where an actual air gap is not maintained between the public water supply and a
private water supply,an approved reduced pressure principle backflow prevention
assembly is properly installed.
(3)No connection exists which would allow the return of water used for condensing,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
distribution facilities installed on or after July 1,1988 and prior to January 4,2014.
(5)Plumbing installed on or after January 4,2014 bears the expected labeling indicating
<0.25%lead content.If not properly labeled,please provide written comment.
(6)No solder or flux which contains more than 0.2%lead exists in private water distribution
facilities installed on or after July 1,1988.
I further certify that the following materials were used in the installation of the private water distribution facilities:
Service Lines:Lead 2 Copper PVC Other
Solder:Lead Lead Free Solvent Weld Other
I recognize that this document shall be retained by the aforementioned Public Water System for a minimum of ten years and that I am
legally responsible for the validity of the information I have provided.
Remarks: Breakroom "A"-Double check valve(DC)on coffee machine,Common Area "A"-DC on coffee machine,Breakroom
"B"-DC on coffee machine,DC on ice machine,Breakroom "D"-DC on coffee macine,RPZ on Ice machine,Executive
Coffee Bar-RPZ on coffee machine(Lead test performed -NEGATIVE),Reception area-DC on coffee machine,Vault at
NW corner of property -DCDA on Fireline &DC on Fireline Bypass.Meter at street SN 85324542 with DC after(Copper
in,PVC out),2nd Meter SN 85324532 with DC after(Copper in,PVC out).
Scott Masdon CI0009995
Inspector Name License Number
Owner Customer Service Inspector
Title of Inspector License Type
3/5/2020 3:00:00 PM
Date Time
A Customer Service Inspection Certificate should be on file for each connection in public water system to document
compliance with 30 TAC §299.44(h)/290.46(j).