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� ,2�,��i� �� �i�V , upon inspectio;� ai tne p�ivate �,va2er distriburian iaciliTies located at
7 K , vvhich is connecied to Lhe �Ci1�� of Ca��el] i✓���.2er Systen, do hereby cercify
that,to the best of my kn wledge:
I�� 11on- N/A
Compliance Coa�pliance
(1) 1Vo direct connection between the public dnn?ting water sup;�ly as�� a �otennal � ❑ ❑
source of contami.Zation exists. �otential sources of coniamination are isolated
from the public water systzm by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connecrion bet�veen the public drinking water supply and a private wa��er � ❑ ❑
system exists. Where an actual air gap is not maintained bet�veen the public water
supply and pnvate water supply, an approved reduced pressure-zone bac?c�lou�
prevention assembly is properly installed and a service agree:�e�aY exisfs for
annual inspection and tesYing by a certified backflow prevention devic�2es2er.
(3) No connecrion exists which would allow the return o�'water used. f�� cor��.ens�ng � p p
cooling or indus�ial processes bacic to the public wate�su�ply.
(4) t�10 pipe or pipe fitting dvhich contains more than 8.0% lead exists in p�vaie �r�a7er ,� [] ❑
distriburion facilities installed on or after July 1, 1985.
(5) No solder or flux which contains more than 0.2% lead exasts in private vvater � ❑ ❑
dis�iburion facilities installed on or after July 1, 1988.
�later service shall not be provided or restored to the private water dis�ibutian iacilaties Ln�il the above conditions are deter?nined to be
in compliance.
I certify that the following materials will be used in the installa�ior�of�lie priva�te waYer dis�iburion faciliries located at
7S� p'�O(.� J7�(�ha � ��- and thaY 2i�e inspector wi11 va1���e campliance during ttze inspec�ion process:
Service lines Lead ❑ Copper ❑ �VC � Other �
Solder Lead � Lead Free ❑ Solvent Weld ❑ Other �
I recognize That this document shall become a permanent record of the aforemen#ioned�'ublic��ater System and tha2 I am legally
respo �ble for the validity of the information I have provided.
v� � � � �
Signa re of Licensed Pl mber kegistration Number
��5� �I / l� 1 �5.
Type of Registration Date
I recognize that this document shall become a permanent record oi the aforementioned Public�Nater System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
�Nhi�e•Customers Copy Yellow-City's Copy Pink•laspedors Copy �