654 Bridge CITY OF COFPELL WAT�R UTILITIES
CUSTOMER SERVICE�NSPECTlOIti
Residential [,�"' Commcrcia] ❑ TNRCCID#�57U�44
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I � A'� ' �
/ npon itispecti�n of the private water distribntiou facilitiss located at
v$y �''�f� �which is connacled to the City of Cappell Water System,do hereby certify
that,to the best of my knawledge;
� Non- NlA
Campliancs Compliance
(1) No direct conntccian between th$public drinking water supgIy and a potantial �/ ' p ❑
source of contami�ati.oa exisu, Pofential sources af contamination are isolated ' '
from the public water system by an aix�ap or an apgropriate backflow prevention
assembly in accordance with Connmission regula�ans.
(2} No cross-cox�nection bstween the gublic drinking water suppiy and a privais wafer � D p
system cxists,�l�lher$an actnal air gap is not tnainiained between the public wat�r
suppIy and private water supply, an apprbved reduceci pressure_�one baekt��w �
, prevention assembly is praperly instalied and a service agreement exis#s for
annual inspectionand tesfi.ng by a cectif ed back#]ow prevenk'►on device tester.
(3} �o connectian exists which wouId aIIow fhe rctum af water nsed for condensing �/ p �
� cool'�ug ar i�tdns�ial pracesses bark ta the public water suppiy,
(4) No pipe ar pip��itting which contains m�re than 8,0%�ead exisis iu private water �- p p
dis�ihudan facilities installed on ar aftez 7uly I, I988. .
(S) Na soider vr flux v�3�ich coufarus mora than 0.2°/a lead e�sts in private water I� , .p• � .. p
dishx�butinn facilities instalTed nn or after July 1,I938.
... .
Water service shaIl not be provided or restored to fhe private water distribution facili,ues until the above eonditi.ons are determined to be
in campIiance.
I ccrtify that tize follo�-ing materials wiI}be used zA tha installatian of tl�e private water distn'burion facilities lc5cated at
6Sy�'��'<< and that tl�e inspector will validaie coznpltaace dwing the iztspeciion process:
Service liries Lead ❑ Copper ❑ PVC ' p ptlier �
5older Lead 0 I.ead Frea �' Solvent Weld �f Ofher ❑
a�
T recoo;'e that this document sha11 become a permanent recarti of tI�a aforemeat9aned Puhli�Water Sysiem and that I am Iegally
responsib for the vaIidity of the infot�ation I have pr�vided.
,+ � f tU
Si�acure of Lice d Plumber Re�istraiion,Number
�t.�p,� �-i�=�s
Tyge of Registrarian Date
I recognize that•this documcnt shali become a peimanent record o�'the afaremeutionod Publi�Water System aad tha#I am IegalIy
r�spon � le for the vatidity nf the inforination provided.
�� .
Signature of I pector Registration Number
�'�' � 7-/� A`�
Type �f Regis�-atian Date
Whia-Cunomett Copy Ye[low.Citys CapY Pinfc•fasPwa�s CaBY