657 Canterbury CITY QF COYPELC��r�JATEIZ UTILITIES
C�IST�MER SERVICE�N�SFECTIOlti
Residentiai [�" Commercia! ❑ TNRCC ID#D57f�040
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I f/��� f `f"`r�� ,�`�'� u on ins e�t3Qn af the rivate wate
r P p r d�s�but�sn facilinss lEc�tGd at
�S7_ C�"��'L��r �'� �which is connected to the City of Cappell Watcr System,do h�reby certify
that,to the best oF my knawiedge;
I� Nnn- NIA
Compliance Campliance
{I� Na dxrect coniaectiun betr,v.een Yhc public drinking water supply and a patenEial �f ' p p
source of cantamination exists, Potential sources af contazninaticzn are isolated ' '
from the pubiic water systern by an aix gap ot an appropriate baekflow greuerrti.on
assembly in accordance with Conamission r�gulat�ans,
{2} No crass-eonnection b�tween the gubIic drinking water suppIy aud a privaie wates Cs��" D p
system exists,���II�tere an actual aiz gap is nof maintained between the pubiic waset
suppIy and private water svppiy, an apprflved radt�ced pressure-aone backflo�� �
, prevention assembly is properly instalied and a service agreement exists foz
annual inspectionand testing by a cerri�ed backflosv prevenkion device tester:
(3} FJo connecrian exists which wou3d aIIaw the retum af water used for condensin� �% ❑ �
$ cooling ar indnstrial pr4cesses back to the publ.ic�vater supply,
{4) Na pipe nrpip��ttFing which contains mare tfian 8,0%lead exists in private watez � - p p
dis�ibuaQn facilities instaIled on or affi�r]'uIy i, 1�8$. .
(S) Na solder ar flux w�ich coAtains z,�,are than 4,2°/a lead exists in privatc water F�/ �p � p
distn`bution facilities instaned an or afier July 1,I98$.
,. •
Weter service sha11 not be pxovided or restored to the private water disi�ibufinn faciliries vntil the above eonditi.ons aze deteim.inad to be
in canzpl%ance.
I ceztify that the fallo�-ing rnaterials�rit3 be used in the installatian of the private water dism'bu#zon faciIities ibe�ted at
�'S 7 J +° and that the inspector wil�validate compli3nce dvri�g the inspecrion pracess:
Service li�es Lsad ❑ Copger 0 PVC ' p Q��r �
5ulder Lead ❑ Z.ead Fr�e �' Solvent Weld Cf Other Q
��
I recagnize that this docvment sha11 become a permanent record of the aforementioned Public Water Systezn an�that I am legally
r�sponsib for the�alid.ity of the inEonnation I have provided. J
,' � f tIJ
Signature af Lice d Plumber Registratzoa�NumtaeF
�.�P� ��-
Type af Re�astrarion Date
X recogxkize that•this d�curnent shaI1 become a permancnt record of.the afarementioned Public Watez 5ystem and Eha#I am icgally
r�sgon ' Ie for tfie validity af the infaririafion praviri�d,
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Signacure qf I pector Re�istratioa Nvmber
��� S r� �-/
'T'ype of Re�isti-ation Date
YJhi¢-Customers Cupy Yalfow-Cit�s CaPY Piok-lasycdofs C.nAY