701 Rock Springs ��'T�l��F��f�PPL i 1,�;;��-�7'��?�J'TILI il?'���
�C�J�'I'cL��il�'���i�°Y���� '�t1�I'i;'�L'T�:�1
]F�����1���a�� �. �aa�r,n�Prs��� � Z'�l�3?'�ID �#�D���flD�1�D
3 ��._�Pi� ���i ��� , upon inspectio:� t�i the p�vz2e ,va8er dislTibutian facilities ]ocated �t
70 ( �Oei4 J1�yih�C Rr�u.e�. , dvhich is connect�d to the �Cit�� of Co,�e31 �s%�ter System, do hereby cercify
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that,to the besi of my knowledge:
� 1Von- �1/A
Cornpliance Co�pliance
(1) No disect connection between the public drin:cing waYer supply an� a �o2en�ial � p ❑
source of contarriination exists. &'oiential 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.
(2) No cross-connection beriveen the public drinking water supply and a private wa�rer � � ❑
system exists. Where an actual air gap is not mai�tained bet�een the public water
supply and private water supply, an approved reduced pressure-zone bactt�lou�
prevention assembly is properly lizstalled and a service agree�nent exists for
annual inspection and 4esting by a certified backflow preve�ti�n de��ice tes2er.
(3) No connecrion exists whicn would allow the return of water used i�i conc�ens�n� � p ❑
cooling or indus�ial processes bacic to the public evater sup�ly.
(4) t�Io pipe or pipe fitting dvhich contains more than 8.0% lead exisis in p�vaie ��vaYer ,� p ❑
distribution facilities installed on or after July 1, 1985.
(5) I�10 solder or flux which contains more than 0.2% lead exists in private �vater � ❑ ❑
distribution facilities installed on or after July 1, 1958.
�later service shall not be provided or restorerl to the priva4e water dis�tributian facil?ties until�he above condi�ons are�eternzined to be
in compliance.
I certify tha2 the following materials will bz used in the installaiion of the priya?e�,Uater dis�ibution faciliries located at
�O� �b�i� �h��l(1�C` I�o��a, and that 23�e iaspec2or will valiciate compliance during the inspecYion process:
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Service lines Lead ❑ Copper ❑ PV� ❑ Other �
Solder Lead � Lead Free ❑ Solveni�Teld ❑ Other �
I recognize that this document shall become a permanent record o�the aforerrbentioned�'ublic Water System and that I am legally
respo 'ble for the validity of the information I have provided.
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Signa re of Licensed P] mber kegistration Number
�a5� ��/l b /IS
Type of Regis�ation Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration t\'umber
Type of Registration Date
�/hile-Customcts Copy Yellow-Ciry's Copy . Pinic-Inspeao�s Copy