2015_0213 §240.47(d) Appendix�. Custou�er Se�'vice inspectian�ertification.
Figure: 30 TAC §244•47(d)
Customer Service Inspecaon Certi�c�te
Name of FVe� Q l vr. ' PWS I.D.�
Location of Service 4`- - -- +
f .
� Reasan fcar Inspection:
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�Existing service where cc�ncaminant hazards are suspeded ....................................A
; . , . . . .................� __ ..__. _. _ i
�Major renavation or e�ansion Qf disnzbution.faetlii�es ................._ .---- --- .�___.
j ��'te�� �����,,upc�a insp�tiou of ths priva�water distzib►�tion f�cilities connected to ti�e
- - - - -- -��-Y . . - ---- _Y _.�_�__-_�__._ -
aforementioned public water su 1 do her�y_cerb�Y_�l�ac, to the lae.st�f m knocvled e: r
_ _.. -- -- ;
.Complia�ce Non-camp�iance _ _:__.__. _. __ _.
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, �/ p ;, Na direck conne�tion be[ween the public dnnking water supply;
and a pote�tial s�ource of�nntamination exists. PQtenaal suurces;
of contarnination are isotated from the pubtic water system by an�
� �. � o� �m ap�r�riate backflaw pr�vention assernbly in�
I
&CC�T�Wlitl��IIl#II1SS1£}Il FCC�11I8ti0I1S.__._ ... --,--, '=-_ _ . I
; � ?. � _-Na cross-connecuon between the public drfnkin� water s�ppiy'
0
� and a private waoer system exasts. Where an actua!air E`.aF is noti
m�ist�ai�d betvveer►the pu6lic water supp�y and a private waterl
� �FFIy,an apgra�r�ed rectueed press�re-zone backtiow gcevenaon�
� asssmbly is properly instalEed and a service agreement exists for
anae�al insgecuon and testing by a certified back#low prevent�on
; __ ���_�r,-—--=�-____..�----_.-_ --__- ---.-
i=_- -_:- _..____Q ---_- =--�: =--�o connecdon exists which would allow the retum of water used�
� � for coader�in�,coaling or inclust�ial processes back to the public�
i water suppl�_- — -_---_.___.._------