455 Twin Pine Ct �3'T`1 aF��JPPL�i;I, '`�;�:�T;s!,�?�JTILI;I���
�CbJ�T�L�I'/I�'F�5�i+�flc�!�;�l IJFE��;�'l�l
Il��9g�1��4a�� �L ��o�rr,n�r���� � T1 i�'r'�II�#�����O�1�D
i ������ ��� ��� , �pon inspection �f t'ne p�,�ate �,v�ter distribu7�an aaciliTies located at
"l S5 �l�v.V1 p��,e Cvvr�. , �vhich ?s co�ected To Yhe Cit�j of Co��ell �riater Sys2en, do h;.reby cercify
that,to the best oi my knowledge:
�� Non- N/A
Complianc� Coinplia�ce
(1) No direct cannection between the public drin:cing water supaly and a �,o2en�ial � ❑ ❑
source of contami�zation exists. �oiential sources of contam,ination are isolated
from the public water systzm by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection bet-vveen the public drinking wa�er supply and a private wa�er . � ❑ ❑
system exists. Where zn actual air gap is not maintained bet�,veen the�ublic water
supply and private water supply, an approved reduced pressure-zone baclL�lou�
prevention assembly is properly installed and a service agree;nznY exists for
annual inspection and tesYing by a ce.�fied backflow preve�iioa�device tester.
(3) No connection exists whicl� would allow the return of water used fo: conc�ensing � ❑ ❑
cooling or indus�ial processes bacic to the public water supply.
(4) 1Vo pipe or pipe fitting which contains more than 8.0% lead exists in pnvate v�aYer � [] ❑
distriburion facilities installed on or after July 1, 1988.
(5) I�10 solder or flux which contains more than 0.2% ]ead exisis in private vva�er � ❑ ❑
distriburion facilities installed on or a�ter July 1, 1988.
�Iater service shall not be provided or restored to the priaate water d.istributian facil?�ies�til the above condic�ons are deter_niaed to be
in compliance.
I certify that the following materials will be used in the installai�on of The pnv��te�vater dis�-ibution faciliries located at
-6 55 �w•1.� p��1� �(��.�,r� , and that Yi�e iaspect�r will vaiidate compliance during the inspection process:
Service lines Lead ❑ Copper ❑ PVC � Other �
Solder Lead � Lead Free ❑ Solvent�leld ❑ Other �(
I recognize that this document shall become a permanent record of the aforerraentioned Public Water Syscem and that I am legally
respo 'ble for the validity of the information I have provided.
� � � � �
Signa re of Licensed PI mber kegistration Number
�5-�r ���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 Registration Number
Type of Registration DaYe
9+'hite-Cusiomers Copy � Yellow-Ciry's Copy Pinh-laspeaors Copy