2014_0311 §290.47(�) r�ppendix]�. Customer Service Inspection Certification.
Figure: 30�.'AC §290.47(d)
Customer Service Inspection Certificate
Name of PV� PWS I.D.#
Location of Service �/)(a /�i r,/C P � 2 P.� (' �.
Reason for Inspection:
Newconstruction......................................................................................�".
Existing service where contaminant hazards are suspected ....................................m
Major renovation or expansion of distribution facilities ........................................0
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I /�/2v�,1.� ���-y�(�� , upon inspection of the private water distribution facilities connected to ll�e
C�m Iiance, Non-com liance ��_�� °f my knowledge:
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l__ _� P .T _ .
aforeme_ntione u �c water su o e_re certi t at, to t e est
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. �, __.._ _ _ _�__._ _ _ . .__
C� O 1. No direct connection between the public drinking water supply
and a potential source of contamination exists. Potential sources
of contamination are isolated from the public water system by an
air gap or an appropriate backilow prevention assembly in
__._ ^ccordanc.e wid� Commiss�on regulat�ons.
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. O 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 tlie public waler supply and a private water
supply, an approved reduced pressure-zone bacicflow preveniion
assembIy is properly installed and a service agreement exists for
annual inspection and testing by a certified bacicflow prevention
assembly tester.
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O 3. No connection exists which would allow the retum of water used
for condensing,cooling or industrial processes back to the pubIic
water snpply__
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O 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.
0 5. No solder or flux which contains more lhan 0.2% lead exists in
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private water distributioi� facilities installed on or after July 1,
I988.
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I further certify that the following materials were,used in_the installation.of theprivate wacer distribution facilities:
f Service lines Lead O Copper O PVC O Odier �
Lolder Lead O Lead Free_!�_ Solvent Weld O __ Other O �_ ____I
I recognize that this document shall become a permanent record of the aforementioned Public Water System and
that I am legally responsible for the validiry of the informalion I have provided.
Remarks:
�n� �,�'.z�_ :�-�� �r S���
Signature of�nspector Registration Number
S���''��` G�5'�e,�'L �c�•L( /� ,v c'��n�
Title Type of Registration
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U � - %/-/y
Date
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