2015_1223 +C�TX 4�'CQ�PELL WA�R'UTILI'I'xES'
CUS'TOMER'SERVIC��'+faPEGT1011:
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� / ��' v �y, i°' � ���2,�1!���'( .ugan inspection af thc ptivate water di�tr�butio�faeilitits lacated at �
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fe.S�l �,�,r' r ' ,,w+�ict4 is connacficrl ta the�ty cf Cagpetl WaYcr Sya�taas,da t�areby cartify
tt�at,ro the best of my kautvladgt;
. � Ncui- l*tl,A.
� . �Omplia�s �oarpliance
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(;1} Na di=ect cozweccion bctwc�n C�'public drinlcing water sul�plY aad a pat�ntiai �le' ❑ C]
an�a af cantamicaution cxis�s. Fc+t�ntial souacc�s af�atiat�ur�isa�latad' .' �
�'rarn t�ie public water systtm by aa air�ag cu am appcop�iate bac�f'!aw pr�r.�atia�
as�crably ibi atc4zdancC wwith Comusissian r�gulzGons. .
(3} Nu czuss-co�ccian bchvcsn tha public drin]dng wat�r supp�y au�a pr�vaic�er .. i� �1 p
system'e�€ia��W'here an sctual a�r gap is aot a�aisitaiacd bctarctn the publi¢water
suPp}�y and�,rtva� waier svpP1Y, an approved��ed pressura-�me backflov+� .
, -greiFcnztiau assembly is prapt�iy iastalicd an� a servi�c agrccm�t rarists fox
annnal i�.spection and tr.sting by a ccrti��d�clt�lpw preveation<devicc tester.
(3) �ta eonnecdon exists�yhich would��ow the zctnm of water used far candeasiag � (� �
, cool'mg c�r iadtutdat processcs 6ack to We pu'biio svater'supply.
C�� '�`��P��F��g�r,rhich cnnt�iz�marc thaa 8s0°!o lead causis ia grivatc wartcr � p ❑
distribnnonfacilittes installad on ar aftc�7uly I�1488.
(S} T+to solder ar flux whicf�cantains marm than U2%o lead exisu in private wate�' � . ,�] ,. .. p
disra`bution facilities iasmlled ast ar afkr JuIX�,198B.
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Wa�cr scrvf cc sbaSl act be gzxrvicie�t or cea�tnrad spr tba prsvate water ciist�"lst�ivn fa�i�cs tma1.ihc abavt�andidans are deteimiaed w be
in c�iliaucc.
.
I ee�ttify that thc foUoveing mabe�iat��v91]be used in the installatian of'thc.private water distn"butioa f�cilitics ldcatcd at
and t�t tha iaspecinr+will validate compllancce during thc i�e�tion p�ess:
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Service lines Lcad ❑ CnPPet Ca PVC ` CI 4tt`iec t,e�
Satder r..eaa o �.eaa'�kY�o �' solveurwela [] other ❑ '
I rcxugnizc that this documcnt sha31 become a pczmaaent rcGard af tfie aforcmentioaed Public Water Systcm and that I em lcgatly
��spcns��for thc va]idiry of ihe in€armndon I Iiave�ravidad.
�'i � of,�fce:�dPlumucr � R�giso*r'adoaNutr�ber
T�pc of Regystra#oa Datc
I zccagaizc that•thLs ductYment sha]I becomc:a pmcaaancnt rceo�r3 of th�afo�emcntioncd P�blic Water Systcru�d t�t I am lcgally
rc5pU�1�fo o validity'ofilte infotmatiqn pioVidetl. rrJJ /}' `
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