Untitled (21) CITY QF COYF�LX,�k'JATEIZ UTTLITLES
CUST(7MER SERVICE�NSPECT10I4
Residential [�" Cammercial ❑ TIrtRCC ID#057004D
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Z �`��� � " ' '`�' ��E%'`f u on ins ecti�n of tI�e rivate water distri6ufiou facili�iss lnc e
f � � at i zt
_�S7 c��'��4° �'� �which is connecied to the City of CappeIl Water System,do hereby certify
that,fo the�Sest of my knowledge:
Tn Non- N!A
�ampliance �ampliance
(I) Na duect con2aectian betrveen Yhc public drinking water supply and a potential �/ ' Q p
source of contam.i�ation exisss, Potenhal sotuces of cantarnination are iso]ated ' '
fram the public water s�stern by an aix gap or an appropriate backflow pxeuer�tian
assernbty in accoxdance with Commission regnlatians.
(2} No crass-conttec�ion bEtween the gubIic drinking water suppIy aud a privaie w�ter C� D p
system exists.�ti�ere an actual air gap is not matnLained between the pubIic water
suppIy and private water supply, an approved recluced pressure-�ne �rackf�o�� �
. prevention assembly is properly instalied and a service agreeme�t exists for
annual inspectionand testing by a certif ed backflo-w prevent�on device tester,
(3) No connectian exists �Ihicfi wou3d aIIow the retum af rvater used faz condeusing �/ ❑ �
x 000I�g or iadnstrial procesaes back to the publie�vater`suppiy,
{4� Na pipe arpip��itYing vsrhich conbins mare rhan 8.0°/a�ead exists sn private water �" C� �
disizibutiQn facilities instaIled on ar aft�r.July I, I�$8. ,
(�) Na soider or fiux w�ich coutains more than. Q.2°/, lead exis�s it� �ivate water �,/ � p • p
diskn'bution facilities inst�ecl on or after July 1,1�88,
.. '
Water service shall not be grovided or restored to the private water distribufian faciliaes itntil the above eauditi.ons are detcn�nined io be
in compliance. ,
I certify rhat tl�e fallowing znaterials wifl6e used in the installatian of the.private wa#er dism'butzon facilities ir5cated at
t's� [ ��°��� t and that the inspector will validate�ompliance dutiug the inspecrion process:
Service Eines Lead O Copger ❑ PVC � ❑ Otfi�r �
Solder Lead ❑ X.ead Fr�e �` Soivent Wetd O Other Q
��
I recn0»e thar this document shall i�ecome a pezmanent recard of the aforementSaned Public Water Systezn and tfiat I azn legally
r�sponsib for the validity of the inf"orniation I have provided.
,� � f{U
Signature af Lice�d Plumiser Registration�Num,ber
�.� D, -, .._
f
Type of Regisirariou Date
X recogzaize that�this d�ctuz�ent sha13 become a permanent record af.the aforetnentioned Public Watcz System and that I am legally
r�spon ' Ie for the validity uf the infarmalaan pravid8d.
���
Signature of I pectar Registration Number �
��'-'� � �� L�
Tyge of Regis�-ztian Date �
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