2015_1021 (2) CITY OB COpFELL WAT��UTI�ITIES
CLTSTaMER SERYICE�NSPECTIOlti
Residentiai [�" Commcrcial ❑ Ti�FRCC ID#E}57U04D
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I '' `��� �"r�� ,"�`� u an ins ecfian of Che ri � t
/ ! f p �z c w a€e r d�s�i 4 u t i o n f a a i P i t i c s l o c a t�d a t
!�'�6 � n�r;� whzatt is connecled to the C'sty of Cagpell Water System,do hereby certify
that,to the best of my kuawledge:
� Non- NIA
Campliance Compliance
�I) No duect connectian between thc ptsblia drinking water supgiy and a potan6al �/ ' p p
souree of contamination e�cisu, Potantia] sources of eontamination are iso]ated ' '
from the pubiic water system by an air gap or an ap�ropriate backt7ow preuen�on
assembty in accaxdance with Comnvission regnla�ans.
(Z} No crass-connectian bstweeu the public dr�ig watsr suppiy and a privaze water i� p p
system exists,�l�lhera an actu�l air gap is not maintained between the pubSic.water
suppIy and przvate wa#er s�rppiY, an apprflved racluced pressure-znue backtlow �
, pxevention assembly is propariy installed and a s��rice agzeement exisLs for
annual iaspectiorLand testing hy a certi�ed bacic#law prevenkion device tester:
(3} No connectian exists whicl�wou3d aIIow tha retum af tivater useci far eondeusing �/` � �
� coolmg ar iadnstrial processes baalt ta thc public�vater supply,
t4) Na pipe arpipe�rtting which contains more than 8,0'/a 1ea+�exists in private water �- p ❑
distribution facilitics installed on or after..Tuly I, 1988. .
{5) Nv saldex or flux rv�ich confains more than. Q.2% lead exisEs in pri�ate waler � � .p • .. p
distri'bution facilities inst�l'!ed an ar after July I,193$,
.. •
WaYer service shaIl not be provided or restored to the private cvater distribution facili,des until the above eandzti.ons are detennined ta be
in cainpliance.
I certify tha the fallawin materials wi11 be used izz the installaEian of the p.rivate wa#er disa-i`bution facilitirs Ir�cated at
y� ��`��"!� and that the inspector will validate coznplianee detring the insgectian process:
Service liztes Lead ❑ Copper ❑ PVC - p p��r
Solder T.ead ❑ �,ead Fzce �` Solvet�t Weld O Other �
a•
I recognize that this document shailliecome a permanen3 recard of the aforementioned Public Water Systezn and that I azn Iegally
responszb for the validity of the information I have prnvided.
,r �. f tfJ
Signature af Lice d Flumbet Regist�ration,NumbeF
�I��;� /
Type of Regisi�rarion Date���T�
1 recognize that•this d�cument shall become a pernianent record of the a[arcmeurioned Public Water 5ystem znd that I am legally
respon ` ie far tfie validity af t�te infaizrtation pravided.
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Signacure of Z pector Re�istzation Number
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Type ofRegish-ation Da#e
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