2014_0313 §290.47(d) �ppendi�_�3. Custome,-�ervice Inspection Certification.
Figure: 30 TAC §294.47(d)
/� Customer 5ervice Inspecdon Certificate
Name of FWS Lit 0< Cv. 'e�� PWS I.D.#
Location of Service �l U Q�C ��G"�t`�� '�� . __
� Reason for Inspection: '
�New construction......................................................................................- ;
u�
Existing service where contaminant hazards are suspected ....................................� ;
�Major renovation or e�ansion of distribution facilities .._.......,... ,.:..._...._._.,..._0 ___ _______ __ __ _j
I !'S��r.(�i �Z`;>�G-rt , upon inspection of the privat�water distribution facilities connected to the
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aforementioned�ublic water_supply do hereby cerafy_that, to the best of my knowledge:
� ---- - -- - .. - -- ------,
1Compliance Non-compliance �
_ - _ --- - __ _ _._- ---- _ _ __ _ ;
- _ , --- ._:__: --_—
; I�' O 1. No direct connection between the public drinking wacer supply�
; and a potential source of contamination exists. Potential sources
i of contamination are isolated from[he public water system by anl
! air gap or an appropriate backflow prevention assembly in i
i accordance with Commission regulations.
_ _ --.._ _, _ ._. _.
;___ :._- _----. �.._--- _-- - _ _
; .� p 2. No cross-connection between die public drinking water suppiy�
' and a private water system exists. Where an actual air gap is not
� maintained between tlie public water supply and a private water
; supply, an approved reduced pressure-zone backflow prevention
� assembly is properly installed and a service agreement exists for
� annual inspection and testing by a certified backflow prevention
� assembly tester____ __
—�-- ..
i_:�-�_--�--____'---.----__--�_--------------�.__.�--------------------_----__- -- _._..
, � ;. No connection exists which would ailow die return of water used
i - for condensing,cooling or industrial prc�cesses back to the public
? water su I .
-------�LY__�_---
!------- ----- --------__—.------------_—---_--..--�_-_-
�-------- -__--------------------------------------
j � p 4. No pipe or pipe fitting which contains more than 8.0% lead exists
` in private water distribution facilities installed on ar after 7uly 1,
! 1988.
l__-.-----------------� -- -- ----_._------____----
__.._1_�..+�_...'_._ _..________�'O__'___.._____.__"__.-___`____--_-__.-__"- .
I }� 5. No solder or flux which contains more than 0.2% lead exists in
private water distribution facilities installed on or after July I,
` ----_- ___ --__ _.. _ .__ --
1988. �---- -------- —_�_-------_..
I further certiFy that the followin�materials were used in the installa�on of the private water distribution facilities:i
_ _ ---_ .____ ._ ___ - --. _._ _
;Ser�ice lines Lead O Copper � PVC O Odier D` �
'Solder Lead Q 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 validity of the information I have provided. �
Remarks:
-�� � �, ,, `�
��3 ��- -- �-v �' �7
Signature of�nspector Registration Number
S�i r-c'y` �,�S�E,r� v L'Li ��i/ E7 L j�¢1�if r�
Ti�le Type of Registration
� 3��� ,t�
Bate
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