733 Rock Springs �'3'�1'�� DF��JPP�,�i;L�;�1.��7'�';z�1'TILI:1����
�C�1J�7'�D�✓I�'ii��i��'�Y?���,Ir'1SP�;�C:'TI;��
Ik��e�9����fl�� �l �rt����rs�a� � Ti��?'�II� �f�D�7i3�0�]4D
� ����i� ���i ��L'it , upon insp�ction of�tne p�v�te �vatEr distribu2ion facilities located at
733 KO� �1��(`.v�_el S� oa�. , whic� is con�ecieC3 to �he �CiT�� of����ell tTl2ter System, do hereby cer'cify
that,to the best oi my knowledge:
� �ion- N/A
Cornpliance �Co�pliance
(1) 1Vo direct connection between the public dnn�cing wa2eY supply an�1 a �o2ennal � ❑ ❑
source of contamination exists. Poiential sources of con2amination are isolaYed
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 drin�'cing water supply and a privale warer � ❑ ❑
system exists. Where an actual aiz gap is not maintained bee�een the public water
supply and private water supply, an approved reduced pressure-zon� bacl,.��lou�
prevenrion assembly is properly lizstalled and a service agree�nenti exists for
annual inspection and testing by a certified backflow preveniion device Yester.
(3) No connection exists which would allow the return o�f water used for cor�c�eaasing � p ❑
cooling or industiial processes back to the public water su�ply.
(4) IVo pipe or pipe fitting which contains more than 8.0% lead exists in pr�vaie �r�aYer ,� ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in private vva2er � ❑ ❑
distriburion facilities installed on or aFter July 1, 1988.
V�ater service shall not be provided or restored to the private water distributian i�cilaties t!n�i1�he above condicions are deter_mminecl to be
in compliance.
I certify that the following materials will be used in the installa�ion of�e priv��±e�,vater dis�-ibution facilities located at
7�3 1�o�� � J'�h��` IS o0.�_ and thaY�e ins�iec2or wi1!validate compliance during the inspec�ion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead � Lead Free � Solveni s✓Veld ❑ Other �
I recognize that this document shall become a permanent record of the aforemen?ioned Public�Vater System and that I am legally
respo 'ble for the validity of the information I have provided.
� � d � c�
Signa re of Licensed Pl mber kegistration 1�lumber
a 5� 1b/ 16`/�S.
Type of Registration 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 3Zegistration Nunber
Type of Registration Da2e
9,'hile-Cusiomels Copy Yellow-Ciry's Copy Pinh-Inspeaors Copy