2014_0311 §290.47(d) Appendix D. Customer Service Inspection Certi�ication.
Figure: 30 TAC §290.47(d)
Customer Service Inspection Certi�cate
Name of PW� PWS I.D.#
Location of Service /� � C'!� � -�
Reason for Inspection: f
New construction................... .................,.....................................,..�� I
.........
Existing service where contaminant hazards are suspected ....................................I� �
MaJor renovation ar e ansion of distribution facilities ,._..._._,.,�._•T_:_^_�•••�•••••��--0-------------------I
I � �,����� �j��f,� ,u.pon inspection of the private water distribution facilities connecied to tlie
aforementioned�ublic water su 1 _do hereb_certi that to the best of my knowledge: _�_�_^.__.,_I
..._ _PP_Y _ Y� �S' - �.___
�Compliance_ Non compliance �__._-�=�-.. �_ --- ----
--- -� - _,_-_�.
-.. :.._
-_._ -,:- _.-_-�_ . _
��i' p 1. 1�Io direct connection between Che public drinle�ng water supp y
and a potential source of confiamination exists. Poten�al sources
of contamination are isolated fram the public water system by an
air gaA or an appropriate backflow prevention assembly in
, accordance with Cornm�ssion regulations_�__.__.__ ,-. ,.::
i - - -: ._ -_- ___...,_ . _,__ ..___ __. -v,. =_ --- _- ____..__-�.�_____ _____ -
__ _._-- _
; ,� p 2, No cross-connection between t�e public drinking water supply
and a private water system exists. Where an actual a�r gap is noC
maintained betvveea the publie water suppty and a private wa�er
supply, an approved reduced pressure-zone backflaw prevention
assembly is properly installed and a service agreement exists for
annual ir►spection and testing by a certified backflow prevention
assembly tester. _ _^� --__----.-_--
p T 3. No eonnection exists wiuch wauld allow the return of water used
^^��^^ � � � for condensing,cooling or industrial processes back to the public
water su PIY� ------- ---�_�—
�~��^` � p� ' 4, �T No pipe or pipe fi�ting wiuch contains mora than 8.0% lead exists
in private water distribution facilities installed on or after July 1,
I -- - -� ----__._.__—.. 1988. �__._..._ _____ — ___.�--=-�.�-=
v�-�^�T p 5 No solder or flux which contains mare than 0.2°lo lead eacists in
�----------
� privace water distribution facilities installed on or after 3uly 1,
198$, - ----- ---
. �_ _._ ..— -
_`!
--- -_-.--_ _ .__.
I furtlier certify that the foltowing_materials were used in the installaEiDn of tiie�rivate water distributton fact ities:
___ _----- --
__ _____. ____._... _ �
�Service lines Lead O Copper Q PVC 0 Other
Solder _ L�ad Ct � Lead Free_l�_ Solven[Welc! O � Other O_--.____.._._...__.--�...
I reco�nize that this docuraent shalt becozne a permanenC record of the aforementioned Public Water System and
that I arn legally responsible for the validity of the information I have provided.
Remarks:
_ � � �,�� -3-�� `�5� `�
Signature of nspector Registrati�n Number
�i ��u /L,.t� �Lj f'yn�
��/�-x!.7� ��S%G,I�Z- a.
Title Type of RegisEration�—
C�� � /�` �L/ _
Date
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