2016_0116 cxT�aF co���z.z,wAr��.u��Tz�s
CUSTOMEIt SERVTCE�NSPECT].OI':
ResidQntiai '� Gammerci;al ❑ TI�RCC ID#05'1fiD4D
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I 4' npon inspecfifln Qf the private wa€er disfribufiou faeilitiss located ac
�"�'r� '� ,wkizch is conneci�ed tp the City of CappelI Water System,do h�reby certify
that,to the tsest of my knowIedge;
� ITt Non- ?�IIA
Cam Iaan e �ampliance
{I) No direct eomlectioxt between Yhs prxblia drznkiag wa#er suppIy and a potential � � �} ❑
source of contami�ati.pn exists, Potentia� sourc�s of cpntaznination are isolated ' '
frem the pnhlic urater system hy en air gap or an appropriate backfIow pre�!erriion
assem,h3y in accordance with Gozx�.mission r�gvlatians. .
(Z� No cross-cozuiec�itiu bstwecn the gu�Iic drinking tivat�r supply and a p�ivaie v�rater � D p
system�exists,�ti�There an actual air gap is not mainta2ned betweeu the pubIic•water
supply and grivate water supply, an approvcd recluced pressure-xone backflow �
, prevention assembly is propezly instalied and a s,ervice agreement exists foz
annual inspectionand#esting by a cer�if ed backfl�tiv praYentian device tester:
(3) No connecrion e�cists which would aIlow the ret�m�af water�sed f�z condensin� (� Q �
S cool'mg ar iadus�al processes back tu tI�e public�vater suppiy,
(4) Na pipe arpipe fitting vrhich aoniains m�re than 8,0%Iead exists in private vsratez � CI CJ
dis�ihution facilitirs insrAIled an or afEex duIy I,I988. .
(�) NO So�d;El L?I fIUX vrhich cau�ins more than 42°/a lead exis�s in privat� water � p -_ • .. p
distn'bution facilities installed on or after 7uiy 1,I988.
y r• •
Water service shall nat be gravided or restored to the priva#e water dishibu[ian faciliries until the above eonditioas are deter�uned zo be
iu coinpliance.
I cer#ify that the fai]aK�ing materials tviI}tae used in the installaEian of tl�e.griva[e�atez dism`bution facilities Idcated at
�� { �o.✓ and that the inspectar�vill vaxidate compliance dt�ri�g the insgecrian pracess:
t .
�ervice Lines Lead O Coppec � PVC ' ❑ Qttier �
5older Lsad Ct X.ead Free � Solvent Weld L7 Othex Q
I recao i,e tbat this documeni sha11 become a pe�mauen#record of tIie aforementionod Public Wa#er$ystem and that I am legally
rasponsib�for the validity of the infortaati4u I hav�pravided.
�
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SignatureL�f'j�c bcr Regislration,NumbeF T�
s�� `��l__/�
Type of Registirarion Date
I recognize that•this docurtxent shalI become a perman�nt recozd of.tlte aforeme�ntianed�ublic Watez System aud tha#I am Ie�ally
respon�ile the va�lidiry af the infa ' avi d. ���
Signalure of I � Registratioa�I�iwnber
��/ . 1'��C� ��C�
Typc of Re�ish-ation Date . �
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