2015_1021 CITY OF CQPPELL WATER UTILIT�ES
CIJSTOMER SERV�CE XNSPECT1Ui�
Residential � Commcrcia! ❑ Tl'�RCC TD#0570n4U
I r�' `���" ��✓� .��%`� u n ins ectian of th
, po p c�nvat�water distri�ufi�n facilinss lnc�ted at
��� ��/U�t//lN' ,�vhicka is connecied ta the Gity of Cappell Watcr System,do hereby certify
that,ro the best af my knawledge;
7n I*�on- 1�IlA
Compliance Compliance
(1) No direci conraecfion betw.zen the public drinking water supply and a potential �' ' ❑ ❑
source of contamirtation exisu. Potential savrcas of Gontnmination are isoaated ' '
frQm the puhlic watcr system by an air gap or an apprapriate backflow prevention
assembly in accordance with Comtnission regulations.
(2) No cross-connection between the pub[ic drinking water supply and a private water �y' ❑ ❑
system exists.� Where an actual air gap is not maintained between the public water
suppIy und private water suppty, an approvcd reduced pressrue-zone backflow �
, prevention assembIy "ss prflperiy installed and a service agreement exisis for
annual inspection.and testing�y a certif ed backf]�w prevention device tester:
(3) No connection exists which would a11ow the retum of water used for cdndensing �y` q ❑
, coo�ing ar industriak processes back t�the public water supply.
(4) No pipe or pipe fitting which contains more than 8,0°/a lead exisis in private water � p O
dis#ribucion facilitics installed an or after 7uly I, I988.
(�) No solder or fIux wluch contai�s more than 0.2% lead exisis in private water �j,/ • p � ❑
dis�ibution facilities instatled an or after July 1,1938.
. .
Water service shall aot be provided or resYored to the private weter disiribution facilities until the above eunditions axe d�tem�isaed t4 be
in eampliancc. ,
I certify that the fallawing materials wiI]be used in the installation�f fhe.priva[e water disa-ibution facilides ldcated at
and that tha utspector will valirlat�compliance duriug the inspectian process:
,
Service lines Lead C7 Cogper ❑ PVC ' O Otlier �
SoIder �,ead ❑ Lead�ree � Soivettt Weld ❑ Oth�r O
��
I recognize that this document shaIl become a permanent record of the aforementinned Public Water Systezn and that I am legally
responsib for the validiry of the informati�e provided. �
� �
Signature af T.ice d Plumber Registiati`4n.Number
k�.��.5 �/�/��
Type of Registrarion D te
I recognize 1hat�this document shall become a pem�anent record of.ths aforementioned Public Water System and that I am tegally
respon ` le for the validity of the infom�cation provided,
���
Signature of I ector Registration Numher
- ��� "� 4�/q/i�
Type of Registration Dat�
Whiic•Customefc CuPY Yellow-Citys CnPY Pinlc-faspcdafs CoAY