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2. 
4. PURPOSE
   The City of West Columbia is responsible for protecting the drinking water supply from contamination of pollution which could result from improper private water distribution system construction or configuration. The purpose of this service agreement is to notify each customer of the restrictions which are in place to provide protection. The utility enforces these restrictions to ensure the public health and welfare. Each customer must sign this agreement before the City of West Columbia will begin service. In addition, when service to an existing connection has been suspended or terminated, the water system will not re-establish service unless it has a signed copy of this agreement. RESTRICTIONS. The following unacceptable practices are prohibited by state regulations. I. No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an airgap or an appropriate backflow prevention device. II. No cross-connection between the public drinking water supply and a private water system is permitted. These potential threats to the public drinking water supply shall be eliminated at the service connection by the installation of an airgap od a reduced pressure-zone backflow prevention device. III. No connection which allows a water to be returned to the public drinking water supply is permitted. IV. No pipe or pipe fitting which contains more that 0.25% lead may be used for installation or repair of plumbing at any connection which provides water for human use. V. No solder or flux which contains more than 0.2% lead can be used for installation or repair of plumbing at any connection which provides water for human use.
6. SERVICE AGREEMENT.
   The following are the terms of the service agreement between the City of West Columbia, Texas and
8. First Name*
9. Last Name*
11. I. The water system will maintain a copy of this agreement if the customer and/or the premises is connected to the water system.
13. II. The customer shall allow his property to be inspected for the possible cross-connections and other potential contamination hazards. These inspections shall be conducted by the water system or its designated agent prior to initiating new service; when there is reason to believe that cross connections or other potential contamination hazards exist; or after any major changes to the private water distribution facilities. The inspection shall be conducted during the water system’s normal business hours.
15. III. The water system shall notify the customer in writing of any cross-connection or other potential contamination hazard which has been identified during the initial inspection of the periodic reinspection.
17. IV. The customer shall immediately remove or adequately isolate any potential cross-connections or other potential contamination hazards on his premises.
19. V. The customer shall, at his expense, properly install, test, and maintain any back flow prevention device required by the water system. Copies of all testing and maintenance records shall be provided to the water system.
21. ENFORCEMENT
    If the customer fails to comply with the terms of the Service Agreement, the water system shall, at its option, either terminate service or properly install, test, and maintain an appropriate back flow prevention device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the customer
23. Street Number*
24. Street Name*
25. Street Type
26. Apt #
28. City*
29. State*
30. Zip*
32. Signature*
    Electronic signature or signature
34. Date*
    Date
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36. 1. Receive an email copy of this form.
37. Email address

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