2015_1021 C7TY OF COYFELL�4'ATEI�UTILITIES
CiJ5T4MER SERYICE�NSPECTI:Olti
Residential [�^ Commcreial ❑ TNRCC ID#Q57�044
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I �`��� f " ' v'`�' ���`� u on ins ectian af tbe rivate waie
_ ��t�6 r � � r d�s��uh�A faaili�ss lncaicd at
,which is connacled to tlis City oi`Cappeli Water System,do hereby ceztify
that,Eo the best of my kuowledge:
Tn Non- NIA
Campliance �ornp]iance
(1) No duect counection beriueen The public drinki�g water supply and a patential (�/ ' Q p
source of contamivatiou exists, Pafentiai sourc�s of contamin3rion are isolated ' '
frQm t�e public water system by an air gap or an appropriate baekflow preuerrtian
assem'b3y in accozdance with Co�unission regula�ans.
jZ} No crnss-connection between the guialic dr�uking water supply aIId a privais�uvater t� p p
system exisu,���ere an actual air gap is not maintained betureen the pubIic water
suppIy and grivate water snppiy, an approved reduced pressure-aone �rackflow� �
, preventian assembIy is properl}r instafled and a s�rvice agreement exists for
annual iuspectio�and tesfing�y a certifed bacic#7Qw prevent'ton device tester:
(3) No connectian exists whic�would a�low the return at'�vater used foz cnndensing � p �
s cooIing ar'sadustnal pracesses back ta the publie�vater suppIy,
(4) Na pipe arpipe�tEing vyhich contains mare than 8.0%�ead exisis in private water �- p O
distributian fscilitics instaIled on ar after.July I, 1988. ,
(5) Na salder or flux which contains mare than. Q,2°/a lead ex.isis in pri�ate water � �[] � p
dis�x`bution faczlities inst�iSed an or after 7uly 1,1988,
.. •
Water service shaIl not be provided oz restored to the priva#e water disttihutian facilides until the aboue eauc�iti.ons are detennined to be
in compliance.
I cettify thak tbe fallau-ing materials wiI]be used zn the in,Eallatian of the private v�rater dism�bution facilitirs I�c�ted at
aad that the inspectar wili validate compliaace dEuing the insQectian process:
Service liaes Lead ❑ Coppec �1 PVC ' C7 Qtlier �
Salder �.eat3 Q x.ead Free �' Soluent Weld O Othez ❑
a•
I recoe;'e that this document shaTl become a permanent reca,rd of the aforemeationed Puhlic Water System and that I am Iegally
responsib for the validity o{the information I bave prnvided. �
/, ` � �
Signature af Lice d Plumbar Regist�atio Num.ber
�sP� �b ����//s
Typa nf Registrarion Date
X.recoguize that•this d�cument shalI become a pertnanent record of'the aFarementioned�ublie Watez System aAd that I am iegally
r�spon ' Ie far tfie validity of the infarmadon pravid�d.
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Signature of Z pectar Registration Number
��� S �f �-�
Ty�e ofRe�isn-ation Date
Whi¢-Castamcr�Copy Ytllow.Ciq!S Cupy Pio1c-IniPW ofs C�PY