2015_1016 ��"T�� DF���JPP�+LI,�,�If�'T;}��?��'T1LI;1'�s,:�
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I ���,1���.� ���i�V� , upon inspection �of the.p�ib�z2e �,v�ter dist;ibu2ian iacilities located at
7�Q 1�,��,1� ,�pr�nn� I�oe�.�, , which �s connect��l to 71ie �Cihj of Co��ell z�i�ter Systeri, do hereby ce�iify
that,to the best oi my knowledge:
�-� Nor- �1/A
�ompliancz �oinpliance
(1) 1Vo direct connection between che public drin:cing wa�er supply an� a poienrial � ❑ ❑
source of contami�zation exists. PoienYial sources of contarnination are isolated
from the public water system by an air gap or an appropriate bac'�flow prevention
assembly in accordance with Commission regulations.
(2) l�To cross-connecrion beriveen the public drinking water supply�nd a private wafer � ❑ ❑
system exists. Wherz zn actual air gap is not maintained bet�een the�sublic water
supply and private �ater supply, an approved reduced pressure-zone bac2c�lou�
prevention assembly is properly uzstalled and a service agree;ne�aY exists for
annual inspection and tesring by a certified backflow prevention de��icv tes2er.
(3) No connection exists which would allow the return o�`w�ater used for c���ens�g � p ❑
cooling or industrial processes bacic to the public water supply.
(4) IVo pipe or pipe fiiting which contains more than 8.0% lead exisis in pi�vaie�Mater ,� ❑ ❑
distriburion facilities insYalled on or after July 1, 1958.
(5) No solder or flux dvhich contains more than 0.2% lead exists in �rivafe vvater � ❑ ❑
distriburion facilities installed on or after July 1, 1988.
V�Iater service shall not be provided or restored to the priva4e water dis2ributian facilitizs�ntil t'ne above condic�ons are e�etermined to be
in compliance.
I certify that the following naterials will be used in the installarion of the priv�'?z tivater�is�-ibution faciliries located at
7�('� Ko�.�. Sd�.h(� ��. and that 2�e inspector wi1]vaiiclate compliance durino t�a.e inspection process:
Service lines Lead ❑ Copper O PVC ❑ Other �
Solder Lead D I.ead Free � Solvent 4Veld ❑ Other �
I recognize that this document shall become a permanent record of the aforemen�ioned�ublic WaTer System and thaT I am legally
respo 'ble for the validity of the information I have provided.
� � � � �
Signa re of Licensed Pl mber kegistration Number
�a 5� �0/1 G� /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 Number
Type of Registration DaYe
9,'hite•Customers Copy Ycllow-Ciry's Copy Pink-laspeno�s Copy