Untitled (38) �3'T�1 DF��C�PP��+�i;L,�,?�f�'7',���?J"TILI:(��:�
�C�IJ�T�L�i✓I�'�������"I?�:��L�i 1�P�;��:'T3��;1
lk���9,v����aa� �. ��a�i���rs�a� � 'Ti l��'�II���S���D�l�D
I ����id.� ���i��� , upon �nspectio� �i t'ae p�is�ace �,va2er distribut3an facilities located �i
�Q'j� L,..e.��_S�� , dvhich ?s cflnnected to �he �Cit�� of�o�pell �rlaler System, do hLreby ce�iify
that, to the best oi my knowledge:
�� Non- �1/A
Co�plia�c� Co�npliance
(1) 1Vo direct connection between che public drin�cing wa2er sup;�ly and a �o2ential � ❑ ❑
source of contamination exists. Potential sources of contamination are isolated
from the public water system by an air gap or an appropnate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection beriveen the pulolic drinking water su�ply�nd a private warer � p ❑
system exists. Where an actual air gap is not maintained bet�een the public v,�ater
supply and private water supply, an approved reduced pressure-zor�� bac?c�lou�
prevention assembly is properly uzstalled and a service agreementi exists for
annual inspection and tesring by a certifed bacicflow prever�tion device�eseer.
(3) No connecrion e;.ists whicb would allow the return of water uszd io� coa��eas�ng � p ❑
cooling or industrial processes back to the public water supply.
(4) No pipe or pipe fitting svhich contains more than 8.0% lead exists in p�vaie waYer ,� ❑ ❑
dis�ibution facilities ins2alled on or after July 1, 1985.
(5) No solder or rlux which contains more than 0.2% lead exists in private vvater � p ❑
distribution facilities installed on or aFter July 1, 19�8.
VJater service shall noi be provided or restored to the private v✓ater dis2ributian iacilaiies��il�he above condi2ions are deternzined to be
in compliance.
I certify that the following materials will be used in the installa�ion of 2hP p�iva'?z�.vater dis�-ibution facilities located at
and t'nat the inspector�vill validate compliance dwiug ttze inspecYion process:
Service lines Lead ❑ Copper � �VC ❑ Other �
Solder Lead ❑ Lead�ree ❑ Solveni bVeld � Other �
I recognize that this document shall become a permanent record of the aforerrbentioned I'ublic Water System and that I am legally
respo 'ble for the validity of the information I have provided.
� Vd �'� �l
Signa re of Licensed Pl mber kegistration Number
�a5�
Type of Regis�ation Date
I recognize that this document shall become a permanent record of the aforementioned�'ublic�Nater System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration 1!'umber
Type of Registration Date
�Nhite-Customels Copy Yellow-Ciry's Copy . Pink-laspeaors Copy