CUSTOMER SERVICE INSPECTION CERTIFICATIONS (Section 290.46) SURVEY FORM

CTWSC TCEQ ID: 0610020

I, (your name required) upon inspection of the private plumbing facilities located at (your service address required) which is connected to CTWSC water system, do hereby certify that, to the best of my knowledge:
(Reason for Inspection required)
New ConstructionExisting service where contaminant hazards suspectedMajor renovation or expansion of distribution facilities

1. No direct connection between CTWSC water system 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. Additionally, all pressure relief valves and thermal expansion devices are in compliance with state plumbing codes. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
2. No cross-connections between the CTWSC water system and a private water system exist. Where an actual air gap is not maintained between the 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. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
3. No connection exists which would allow the return of water used for condensing, cooling or industrial processes back to the CTWSC water system. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
4. No pipe or pipe fitting which contains more than 8.0% lead exists in private plumbing facilities installed on or after July 01, 1988. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
5. No solder or flux which contains more than 0.2% lead exists in private water distribution facilities installed on or after July 1, 1988. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
6. No plumbing fixture is installed which is not in compliance with a state approved plumbing code. In ComplianceOut of ComplianceNew Construction Can Not Be Determined At This Time
Tester Name (required) Your Email (required) Tester Number (required) Record Test Date (required) Where a serious threat to the public health or to the public drinking water supply exists, CTWSC shall not provide water service or restore service to a private plumbing facility until the above conditions are determined to be in compliance. I further certify that the following materials were used in the installation of the plumbing facilities:
Service Line To Structure (required) LeadCopperPVCOther By Plumber (required) YesNo Service Line To Solder (required) Lead FreeSolvent WeldPVCOther By Plumber(required) YesNo Service Line To Main (required) LeadCopperPVCOther By CTWSC (required) YesNo By Plumber (required) YesNo I recognize that this document shall become a permanent record of the CTWSC and that I am legally responsible for the validity of the information I have provided.
Digital Signature (required) Project/Plumber Firm (required) Texas Plumbing License (required)