2015_1030 CITY OF C�?PPEL�WATER UTIS�ITLES
CUSTaMER SERVI�E�N�SPECT10Pt
Residentiai L�" Commercial C] "TIriRCC ID#0570040
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I f i `���� � - ` v'`�' ,"�'`� upon inspecti�n of the rivate wa[er distribu#iou f '
F acxhnes focaced at
�j�3 -�o/'P�►n��� �1.� �4 �whzch is connecied to the City ofCappell Water Syste�n,do hereby certify
t hat,Eo�f my k�qowledge;
� Non- 1.rIA
�amgliance Campliance
(Ij No dxrect cannectian between th$publia drinking water supply and a potential �J/ ' p p
source of cantami.aatio❑ exisrs. Potential sources of contazninatiQn are isolated ' '
from the public water system hy an air gap or an approgriate backflow preventinn
assembfy in accosdance witl�t Cozzunission regnla�ans.
(Z} No cr�ss-connection between fhe gubIic drinking watcr suppLy aud a privats wates C� D D
system exisu,'�zlherc an actual air gap is n9t maintained between the pubIic water
srspply and private water suppIy, an apgrflved red�cr.d pressure-zone hackfIow �
, prevention assembly is properiy instalied and a service agreement exisis for
annual inspeetior�and testing by a certi�ed back#]aw prevention device tester,
(3} No connecri�n exists whic�would aIlow the rcturn af water used faz condensin� �/ p �
S cool'mg ar�dustrial processes back to the pnblic water suppiy,
(4) Na pipe arpipe fttting which contains more than 8A%�ead exisfs sn privzte water � - p 0
distiibutian facilitzes installed on or aft�r Jufy i,I988. .
(5) No soider or filux urbich coutains more thau Q,2°/a lead exisEs itz }srsvate waier � � .p . .. p
dish�'bution facilities ins2�led an or after July I,198$.
,. •
Water service shaIl not be provided or restored to fhe private water distribution facilades nntil the above eauditi.ons are determined to be
in compliance.
I c�fjr�at thc fallo�-ing materials wil}be used in the installafi�n of the grivate wa#ez dism`buti.on facilities Idcated at
_ �C� _ �'i•.� (�-� �-�, and that the inspector�vi1l validate�ompliance dfu�ing the inspecricm process:
Service Iiaes Lead O Cogpe� L] PVC ' ❑ p��r
SoFder T,ead L] L,ead Frea �" Snlveat Weld p Qther p
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I recDgnize that this docvmant shail become a permanent recard of thc aforementioned P[�blic Water System and that I arn legally
responsib for the validity of the informatifln I I�av�pravided. �
, ` � �
5ignatureaFLice dPlumber Registration,N ber
�1:�p� ' . d ��� 7pj�
?ype of Registrarion Date
Z recoguize that•Lhis d�cument shall become a permanent recuzd af.the aforementiQned Public Water System aad that I am 3cgally
r�sgon ' Ie far the valfdity of the mfarmatian provided.
• #-��j
Signahus ofZ pector Registration Number �
��`-'� � �r �,,1
Type of RegistraEion Date
14hi¢-Cu,stamcrc Cuyy Ya{low.Ciq?s Copy PiaSc-[¢sPectafr CeAY