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2015_1217 lyl l 1 lJl" tVYCC,'LL �ti�i r.Fc i�i iii i itS �� �j�, L t:��u:»tx 5�,x v ti..� i:r;�r�u i ii�� � � Residential C� t'omrtterciat t_,J 1"rit[:L: !ll�U57UlWU \ a. —:—, 1 r X i �C_>f�_�+�..� t `t_ �� � r�_�_____,�pon inspectioia of the �r���ate water distribution facilities located �rt ti� V� t.._J�!`��y,�_.___�..�-:.�Y_.i�.`__.,..,_.,.�..�.• �.t.:.t �a �ili��::.i.;..�i :i.r i:w �� j�:,t:lvYY'+:�i �tr_.,,_ r�a..�.i, s�t�...,4`. "..:r,. u��a� i� .�.�� ... .. .� that. to thr best of mv knawledee: All t�Ull' `��t�t i..hIT1FY16811Ce l.qlTl}?Ii8T1C� (t) [vo nucct cannc�r�an uetwccn cna pubiic cinziicm�; w•a�er supp�y ana a �oicntzai `�;u w u source at contamuiano� ex�sts. Yotennai sources ot Contarntnat:on are isatatca from the pubt�c wxat�r system by an a�r gap or an appropnatc baskttow prevenhon assernblp�in aceordance u�ith!_'�mmiss�on regulatyons. (2) ti'a cross-cannecncan laetwe�n the publxc tirinking water supply an�i a pri�ate water � ❑ p systtm exiscs. u`here an actval air gap is n�t maint�ined brtween the publ�c water supqlv and vri.�ate �'aiet Supqly, an approved reduced pressure-zone backfto� arevent�on assemblv is arot�erlv ins�lled arid a sen•�ce aereemenc cxis�s for anm�ai i�m�cn�n and tesrinQ bv a ctrtified backfl�w nre��ention device kester. /71 �1n rnnn�rtinn rvectc u�hirh wnnl� a{l�w thr rrfiim nf watPr i�crri fnr �nnriencanp �i1 C�1 rl • , �..nlint+n.inrincrr±ai nrnrr�cc.a har-k tn thr m�hlit'wAtrr e��nnlv Y � '--'--v , . . . . /A\ Al,�,. ,�Ftt:ti,i i�,►�:,.F� r.nnro:..c mnro tl+ar+ �w'(1�� �na�nvittc �n n.n��atr�t-alnr �i+4 I""i ('1 .;+.r n...:.. � .� .... �..�.' ..' Y't" .....,.'O _"'_" '.._......... ...,..-. ...,.... _ . . ...... . .. _._ � .. _ ..... ,,.� _,... o .i:.w�:t,...:..� �...,.1:....�:..ee�ll...i.. �f:.,. 1..1.- f 19CA uWu�vu�av�a �w..�.e��...e uwr.w.�.... ..... ... .....�_ . .} �. �. .... rfi 1• 1} fY l,'..1. ........."... .�...._. �L..... /11Af I�_.7 e..:«... .� .—,...�.� ''7 � P1 r"1 ,.1r 1�V JVYLIrI V! llLLA »Lll�.tl 1�lY1lLG1lt.) A14V1�. J�liit �v.r u ��.YU' �..�i]�.> uv P.���ru.� ..ue�.i •�,�y„y �../ {,� ' R. Y �h[�(+ UISUlUU41Ul/ lGl.11l11C5 i1lJltll/GU Vfl lYl tl14G1 J4{5 �r iIVU. v►-atcr srrv►ce st►aii na���r�vi�iea ar rescurca�o ti�e pri.a�r �wa�c, u,�u;tau�n;m i�c�����c��,u�ii u�e a'a,�e`u��wuuu��!e uc��►�ru►,eu w'vr in comptiance. I certify thai the followmg mat�nals wiU hc used rn the mstallahan ot the pr���dte u���eT d�smGuttion tar.,lNt�es tocate�at �` � � � r� ��lld ,..a,k„�.►,e .,.,..«., ,:��....,:,,.�.a,,,...,...�;...,,...,�.,n.. .�,.,.,�., .n,.A.-... �Q�__ _ _______�a_ _.... .,,..., �.�. W._ �. r._�.._ .._ .�.,..�.,. .__..r.e�.._, ..._..�_o ... �._r�. ..�_.t..,._�.._. �. Service Im�s Lead ❑ Copver ❑ 'r�t`C E3 �`Jther �- IE;.� Sntdtr Lead C7 Lead Frce CJ 5o1�°ent W'eld :r Gthet {,�. __ _ i T�cntm�7t thar th�<rin�-�rmenr ch�ll hrcnme a nermaneni reccrrai nf ihe a(��rrmenfrnneif Puh{ic Vl'ater SvsCem and that 1 am leeallv rPcti?�ncihlr{nr fFP w�aiiriirv nf thr infnrmat4�n f ha�r nrm�i�ip� C " _ f ,� � �. i ,t ;r•_ h. ,��. �...� 1-_ �/.. � :y ,�. _,� __ _�_... „� ------_. _ .____s_.--_____. . ..___ __.._._.___.....______ _--_____ C1f1M.fi�rP n�'1 : .,cpa Ai.Frr.F+er G:.,r�c�n�tinn�'�.mhn� r� ....b...�....,_ ._ .___ .. ....... .. ., � __. � � � �w:,: i1�'� i' ____�.__ __ _------ .__ _ ___--- � � ��. � ._. __. __..._,. . __. . _..____. _ Type of Registration i>a�� 1 reco�tniu that this dacumtm shalt become a�rntianent re�ard ai the atorement�c�ne� C'unlic V1"atet S�•ytem and that f am ie�;allti• res�sible for the validyn�of che intorrnaaion tara��►ded. � ' _ r � r . ,Y„_ f,I ; ; �-,., �. I`�Y��. ..,-�._._ j ..��t ( =a t _.x,. _.._. _.^_ __ ___ _. . _ S�en�ure�f fncnec►nr Rroastratron tiumhcr Y` f � r �h-+ r-'y i � � j Y•-# s+ ...� ...... . !Y � � ._ . �,.,, ' � {� _"__ _�.'__ '_._..,_ ... .�.,......_.__ ..,.__�_._.. __._....._..__._._-._._....._�._�_.. Typc ot ltegyscrat�an �!aty ...._ �_.._.,».. w ...�. ... . . �.. ...��,,,,,>w�,,,