2015_0327 §290.47{d) Appendix D. Cc�stomer Service InspectiQn Certif'ication.
Fi�ure. 34 TAC §294.4?{d)
P� stou�er Servioe Inspectian Certificate
Pi7VS i.D.#
Name of F�hh�' ��
L,ocaaon of Service �l r G C --- .
�___ _. -----
� Reason for Inspection:
...................� �.
�New con�ruction............ ................................... '
.........t r��Tas az��us �a
�here contaminan p ...................0�
�Existing service + ................. _ -
jMajor r�novation or e_ a�sion of distribu�un fac�ities ..............:....__.:...._._._.:�_..�..__.__._..__ .._ +
i !�<��.+%'�t�,";9��� _, upan inspection 4f the private w�ter distribe�tion facilities connected to che
aforemenEioned public water suFQ�_do hereby_certif�chaL, to the best of my lcnowled e�-. __._------- .
--..
____._. _ .. :
�Compiiance Non-complianc;e . ,__ ,
- -. _ _.__.._
--- -.,.___.__ __ _
� � p 1. No dire,�t cos�nectian between [�e puhlic drinking water supplY;
a,nd a potential source of cc�ntamination exists. Pr�[enaal sources;
' af conta}airtatiQn are isotat�d from th� public water sy�te�►by an�
air gap or an appropria[e b�ackflaw pre�+en�ion assembly in i
♦• accc}}rcla�oGe �rith Cornm�ssion_re�gulatit�ns__.._ _.-. --- _. .. _ . �
; / 2. No erc�ss-connec�ion betwesn the public drinking water supply�
Q �
a.nd a Frivate wat�r system exis�s. Where an actual air gap is not'
���1���,�en the�hlic water sug�ly a�d a private water'
����,�an�������c}��pre.ssure-�one backtlow prevention
' assembly is praperly installed and a servitce agreement exists for
4 annual inspect'son and testiug by a certified backflow prevention
j assennbly tester.
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_ __—__,_-----_--_=._-�.---___—_--- _
j=_- _ - __'-—-=-_— _0 ----- --=3. =---1'�To cannection exists which woe�ld allow the retum of waoer used
� � fur cond�ensing,coo�ing or indus�ial processes back to the public
' --�
i water suPP�Y__-=_-=__-- ----- --—_—__-=-.
' — -- --------�—_—_— =-___
_.__�_.�__— --
-._� --
_
, p 4. I�to pipe oi gipe f�tting which contains more than 8.A%O lea exists
in private water distributicm facilities installeci on or after July 1.,
{ 1988. ;_�._—^____�_====-e._-
�_---�--_�:--_:----::_--__—__—_—_�=--�
--=-
� � p 5. No solder or flux vrhich contains mo�re chan 0.29b lead exists in
private water distrihutiau facilities install� on ar after July 1,�
; 1988. _ -_�_____._ ---
, _ .___«.--
_._.
-- -
_ ----
, ____ ---
I further cerufy that the following materials were us�t_en the ins�allau°n of the_private water distnbutmn aci i ies:i
__.. .__ _ _ - i
_. _ __ Other �
;Service lines Lead Cl Copper � PVC Q 1
Lead Q Lead Fr�__ Solvent Weld Q _____ Other -- O—------, . - -
`Salder _ --- �----�_�
I recognize�that this document shall beeome a permanent recard of th�afore�entioned Pufilic Waaer System and
ehat I am legally resgonsible for the validiry of ii�e informatron I Y►ave provided.
Remarks:
,� �� --�_���., C�?�. "
_�;�S` �,�.� �. -------------
Signature of i"nspector Registrat'ton Nu�cber
�-��� G�5;�.� ��u �rv P`�'1�`
S`�`� Type of Registration
Title
- `31z� 1 �s
Daee
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