Untitled (25) '�3`11'jl SJF';��JPP�+Li1,�i;/��7';'rr �J7'1I�I il?.�r-.J
�i.LLJJ1�Dl✓1'-�1'1 J��a��Y�1��L 11'�Is7P'L�S�ll�''JJ'�l
]F���9�1������ �, �a�gnr,n�ar�a�� � '�I'�li3?'�IID k��B���00�1�
� ����i� ���i��� , upon inspection af t'rae p�vatz ivater distri`uu2aan facilities loczted aP
t'� S� l.�b�c�-+��+.�5 ��nVt� , which ?s cflnnec�e�] to �P-i� Ciri� of���aell �,�✓ater System, do her�by cercify
that,to the best of my kno�xledge:
1n i�1on- N/A
Cor�pliance �o�plia�ce
(1) No direct connection between the public drin.'cing wa2ez su�ply an� a po2enrial � ❑ ❑
source of contamilZation exists. Poientia] sources of contamination are isolated
from the public water systzm by an air gap or an appropnate backflow prevention
assembly in accordance with Commission regulations.
(2) I�do cross-connection bet-ween the public drinking warer supply and a pnvate wa��er � p ❑
system exists. Where an actual air gap is not maintained bet�ve�n the�u'oiic yvater
supply and private water supply, an approved reduced pressure-zone bact��lou�
prevenrion assembly is properly u-�stalled and a service agree�eraY exists for
annual inspection and Yesting by a certified backflow prever�tion det�ice tester.
(3) No connecrion exists which would allow the return o�'water used ior conc�ensn�g � p ❑
cooling or industrial processes back to the public water supply.
(4) 1�10 pipe or pipe fitting which contains more than 8.0% lead exists in privaie warer ,� ❑ ❑
dis�iburion faciliries installed on or after July 1, 1985.
(5) I�10 solder or flux which contains more than 0.2% lead exists in privaYe �va�er � p ❑
distriburion facilities installed on or after July 1, 19SS.
Vzlater service shall not be provided or restored to the private wate�disYribuYian facilaties�n�il ihe above condirions are ceter_mined to be
in compliance.
I certify that the following materials will bz used in the installarion of the priva?e tivater dis�-ibuiion faciliries loca2ed at
��?_� 1�0��►^��wr O�(1�/c_ and that t�e inspector v✓ill va1_idate campliance during the inspec�ion process:
Service lines Lead ❑ Copper ❑ PV� ❑ Other �
Solder Lead ❑ Lead Free 0 Solvent�sVeld ❑ Other �
I recognize that this document shall become a permanent record of the aforementioned Public�Velater System and that I am legally
respo 'ble for the validity of the information I have provided.
� � d � �
Signa re of Licensed Pl mber Registration Number
��5�
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Nunber
Type of Registration Da4e
While-Customels Copy Yellow-City's Copy � . Pinh•laspeao�s Copy