2016_0919 (2) �� Texas Commission on Environmental Quality
�ustomer Servicelns ection Certificate �
Name o� WS: Cit of co ell
PWS IlD#: 0570040 ;::
� Locatic�n of Service: ��,d�� `f '� ,��- �•�; � � �
w �; �
Reason for inspectian: New construction....... ......... #'
. .. ......... ,,
... . �
Existing service where contaminant hazards are suspected....,....,.. ❑
Major renovatton or expansion of distribution faciHties..................... ❑
� `��" X��� � ;�`' �� � �:� , upon inspection of the priva#e water dis#ribution facilifies
connected to #he afor�` entioned pubfic water supply .do hereby certify that, to the best of my
knowledge:
Com fiance Non-Cam liance
��� No direet connection between the pubfic drinking wafer supply
� � and a patential source of contamination exists. Potential
sources of contamination are isolated from the public water
system by an air gap or an appropria#e backfl�w prevention
assembly in accordance with Commission re�ulafions.
(2) No cross-connection between the pubfic 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 ins#alled and a serviee agreement �'`
exists for annt�al i�spection and testing by a certified backflow
prevention assembly#ester. '
(3) Rlo connection exists which woulc!aliow the retum af water used
��� ❑ for condensing, cooling or industriai processes back t�#he public
water supply.
(4) No pipe or pipe fitting which contains more than 8.0°l0 lead exists
�e ❑ �n private water distribution facifities installed on or after July 1,
1988 and prior to'January 4, 2tJ'�4.
(5) Plumbing installed after January 4, 2014 bears fhe expected
I�� p labeling indicating _<0.25% fead contenf. If not properly labeled,
please provide written comment.
(6) No sfllder ar fiux which eontains more#han 0.2% lead exists in
� ❑ private water distribution facilities instafled on or after�July
�, 1988. �
I further certify that fhe following,materials wers used 'n the installation of fhe private wate�distributio faciliti�s
Secvice lines; Lead ❑ ` Copper � PVC � ` Other ❑ ��'� � �. ��' ,� :
Solder; � Lead � ❑ �Lead Free So�venf Weld ❑�� � �C3ther � � ����` � � ':y.�',���.�.��, �:�����,�s�;
I recognize that this document shail become,a permanen#record of the aforementioned Public Water System and
that I am �e ail res onsible for the validit of t e t formation I have rovided. ��� ��� � ��.�..��,�,,,V
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� Re�'istration Num6er: �'
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Date: '�` ��:.. � ..,�..
White—City Yellow—Customer Pink-inspector