641 Springlake CITY L)F CQPPELL WAT�R UTILITLES
CiJSTOA�IER SERVTCE�N�SPECTIOlti
Residential � Comrncreial 0 TNRCC IIl#057U040
1�
I f�' `��'� �~y�' ���`� upon inspectic�n af th$ rivate wa€er dis�ibufion faci i '
F ��ss�aca[ei xI
��� �'r`— ���� wkuich is connecled to the City oi`Cappell Wafer 5ystem,do hereby certify
that,Eo the tsest of my knawledge:
Tn Non- A'!A
Compliancs Comp3iance
(I) No duect connection between Yhe public drinking wat�r suppIy and a poten�ia� � � p p
source of contamivation exxsts. Pofential sources of contamination are isolated ' '
fram the public water system by an air�ap�r an apgropriate backflow greverrti.an
assembty in accozdance with Commission reg�lat�ons.
(Z} No crass-connecsian between the gu6Iic drinlring�rater supgiy aud a private vvater �' ❑ p
system exists,�l�lhere an actual au gap is nof maintaIned between the public water
supply and private water supply, an appr�ved reduced pressure-zone backflow �
, preventian assembly is properly instalied and a service agreement exists for
annual inspectioriand testing by a certi�ed backflazv prevention device tester.
(3) No connectian exists zyhicfi wauld aIlow the rctum of�vater used£or condeusing � Q �
S cooI'mg ar�[dns�zal processes barlt to t4�e public�vater suppIy,
(4) Na pipe or pip�fitting which conbins more than 8A%�ead exists in grivate watez t�' - p p
distribution facilities instaIled on ar aftex�Tuty I, 1J88. ,
(�) Na solder or flux v�bich coafains more thaa 0,2°/a lead ex.ists in privatc water �/ � p � p
dish-��ution facilities installed on or after Juiy I,I98$,
.. .
Water serviae shaIl not be provided or restored to the privafe water distcibutian facilides until the above eond�tions ara deteRnined to be
in coznpIiance.
I certify rhat tl�e falla��ing materials wilT be used iu the installatian of the grivate water dis��ution faciI�ties ldcated at
and that the inspector tvili validate compliance during the inspection process;
Service tines Lea,d ❑ Copper O PVC ' � Otlier �
Solder �.ead C7 L,ead Frea �` Solvent Weld Cf pther ❑
�-
I recagnize that this document sha11 become a permanent record of tIie afnremeatiancd Fuhli�Water Sysiem and that I am Iegally
r�sponsib for the vali�iity ot'the information I hav�provided. �
,� � �
Signahue af Lice d Plumber Registration.Number
�}.��,� /v//6t��S
Ty�e ofRegisirarior� Date '�� � -
I recognize that•this documcnt shall become a permanent record of the aForementianed Public Water System aud Ehat I am legally
respon ' le far iiia vaLidity af the inf�rmabon pravid�d.
���
Signacure of I pectar Re�istration Number
��"� � i� J r '�,� -�-/5
Typc ofRegis�-zfion Date
Whi¢-Gasomc��Cupy Ya[fow-CitN.t Copy Piok•InspMa�sC.nFY