445 Columbus Dr �'3�'�l �F•��.��JFP�+�i I,�;;��-�Tr�iJ'TILI;I?'��:�
�iIJ�'3'�1✓I�'����i?�Y7��L�i 1�Pi��:�3�1
lE����m��nt�aa� �. ���r,���rs��� � �[i'1��t?.:.'�ID#�D����3�1�D
I ��1,�.,��i"� ���i�4� , upon Lnspec�tio� �of ine p�:��te rva2ei distribu2ion iacilities loca2ed �i
���5 eu<<.v.�bu�s 1✓r�Vr� , �vhich �s �con�ecied to Yhe �Cit�j of�o��ell �,�iatzr S�ste�n, do hereby ceriify
that,to the best of my knowledge:
�� i�ion- N/A
Co�pliance Compliance
(1) 1Vo direct connection bet�veen the public dn.-i:cing wa2er sup;�ly and a potential � ❑ ❑
source of contamination exists. Poiential sources of coniarnination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Comrnission regulations.
(2) No cross-connection beriveen the public drinking water supply aud a private wa�er � p p
system exists. Where an actual air gap is not maintained betwween the public water
supply and private water supply, an approved reduced pressure-zons bacl��lov,�
prevention assembly is properly installed and a service agree�nz�aY exists for
annual inspection and testing by a certified backflow preve�tic�r�device tesrer.
(3) No connecrion exists which would allow the return of water used for c��c�ensing � p ❑
cooling or industi-ial processes back to the public water supply.
(4) No pipe or pipe fiiting which contains more than 8.0% lead exists in privaie�r�ater ,� ❑ ❑
distribution faciliries installed on or after July 1, 19�8.
(5) No solder or ilux which contains more than 0.2% ]ead exists in private �vater � ❑ ❑
distriburion facilities installed on or after July 1, 1988.
V�later service shall not be provided or restored to the private water dis4ributian facil�tizs util t'ne above conditions are deter_mined to be
in compliance.
I certify that the following anaterials will bz used in the installaiion of 2he priv��?e�,Uater dis�-iburion facilities located at
� ��� (-o��^'��C �V1V�C._ and that�e inspector will validate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead � Lead Free ❑ Solveni�Veld ❑ Other $ffi
I recognize that this document shall become a permanent record of the aforemenYioned�'ublic Water System and thaT I am legally
respo 'ble for the validity of the information I have provided.
� � � � �
Signa re of Licensed Pl mber kegistration Number
,��5� lo/ I 6/IS
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned�'ublic Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
White-Custome/s Copy Ydlow-Ciry's Copy Pink•lacpenofs Copy