Untitled (41) §290.47(d) Appendir D. Customer Service Inspectiou Certification.
Figure: 30 TAC §290.47(d)
Customer Service Inspection Certiffcate
PWS I.D.If _____
Name�t PVkS ��.—.��->-- , ----- --
Lc�cation of Service��-r��» '
Reason for Inspeceion: —
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'New conscruction................................... .
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�Existing servi�e where contaminant hazards are suspected ................... O
, _.. �
;Major renovatic�n or expansion of distribuuon facilities .......•••..•..••.••�•�•�•••����• •
, � �
I <�,���N .��.�,���'� , upon inspection of the private water distribution facilities connect�ed to ie
aforementioned public water supply do hereby certify thac, to the best of my knowledge._ _
Compliance Non-compliance
� � 1. No direct canriection between the public drinking water supply',
and a potential source of contamination exists. Potenrial sources,
of contamination are isolated from the public water system by <t�l�
air gap or an appropriate bacicflo�u' prevention assembly in
accordance with Commission regulauons• _ '
0 2. No cross-c;onnection between the public drinking water supply
� and a priva[e water system exists. Where an actua] air ga� is noc
maintained between the public water suppiy and a private water'
supply, an approved reduced pressure-zone backflow prevenaanf
assembly is properly installed and a service agreement exists for'
anntial inspection and testing by a cenified backflow prevention�
assembly tester. _. . -_._ �
_ _
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� p 3. No connecuon exists which would allow the return of water used;
for condensing>cooling or indusoriat pracesses back co the public�
� water_su ly. ____ . - __ __ ._ ._ --- -
: -_ ..-_ _. _ _ _._ _. _ `
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� � 4. No pipe or pipe fitung which contams more than 8.0� lead e:cists�
in private water distribution fac�hues installed on or after July 1,�
1988. _-.- _ .� _ ;
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�% rJ 5. No solder or flux which contams more than 0.29b lead exiscs ►n,
pnvate water distribution facilities installed on or after July 1,�
1988. �
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I further cercity thac the following ma.terials were useci in�e installadon of the private water distribution faciliues:I
_ Other 0'
,Service lines Lead O Copper O PVC O ;
Solder Lead _ O _ Lead Free t� Solvent Weld O_ -_-- _ Odier _ O__ '
___ . .
___.___.___._ _
_.. _
1 recognize that rhis document shall become a permanent record of the aforementioned Public Water System an
tl�ac I am legally responsible for the validity of the infortnation I have provided.
Remarks:
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X, _ `-?���_ ,�- :��� r�
�.�-�� -- Regisuation Number
Signawre of inspector
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S�,�-C1` � -5/� �2 -- f` • I
"I'i�le Type of Registra[ion
Date�
16 0}'19