2016_0830 Texas Commission on Environmental Quality
Customer Service Ins ection Certificate
Name of PWS: Cit ofi Co ell
PWS I D#: 0570040
Location of Service: " '
Reason for Inspection: New construction.............................................................................. �
Existing service wh�re contaminant hazards are suspected............ ❑
Major renovation or expansion of distribution facilities..................... ❑
�
I Q�'S , upon inspection of the private water distribution facilities
connected to the a ementioned public water supply do hereby certify that, to the best of my
knowledge:
Com liance Non-Com liance
��� 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 backflow prevention
assembly in accordance with Commission regulations.
(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 the public water supply and a private water
supply, an approved reduced pressure principle backffow
prevention assembly is properly installed and a service agreement
exists for annual inspection and testing by a certified backflow
prevention assembly tester.
(3) No connection exists which would atlow the return of water used
[� ❑ for condensing, cooling or industrial processes back to the public
water supply.
(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 and prior to January 4, 2014.
�5� Plumbing installed after January 4, 2014 bears the expected
p/ ❑ labeling indicating _<0.25% lead content. If not properly labeled,
please provide written comment.
(6) No solder or flux which contains more than 0.2% lead exists in
6� ❑ private water distribution facilities installed on or after July
1, 1988.
I further certify that the following.materials were used 'n the installation of the private waterdistributi facilities:r
Service lines; Lead ❑ Copper � � PVC � � Other ❑ ��► ���ing 4�ry�
Solder; Lead ❑ Lead Free Q� Solvent Weld ❑ Other ❑ C c�pe� p��i�'1g
I recognize that this document shall become a permanent record of the aforementioned Public Water System and
that I am le all res onsible for the validit of the information I have rovided.
Remarks: �
�' � i � � � ��
e � , �'rik
Si nature of Ins ector: Re istration Number:
Title: { T e of Registration: �C� �pr
Date: — —'
White—City Yellow—Customer Pink- Inspector