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]l���g�1�nfifi�� � �a��r,m�nrs��a� � T�R�'�ID�;�D����04�D
� �����i� V��i��� , upon insp�ction af tn�p�iti-�te yv�ter distribu2aan facilities located �t
���b �W��� iV�� W�,►v� , �vhich �s co�ected to �he �Cit�j of����e�] t����z� �ys2ern, do h�reby cercify
that,to the best of my knowledge:
� iVon- �T/A
Cornpliance �Co�pliance
(1) ]Vo direct connection between the public drin:cing water su�nly a�d a �otential � ❑ ❑
source of contamination exists. Poienrial sources of coniaminarion are isolated
from the public water system by an air gap or an appropriate backflo�N prevention
assembly in accordance with Commission regulations.
(2) 1�10 cross-connection beriveen the public drinking water su�ply and a pnvaie wa��er � p ❑
system exists. Where an actual au gap is not maintained between the�ublic water
supply and private water supply, an approved reduced pressure-zon� i�ac?c#lov,�
prevention assepnbly is properly installed and a service agreement exists for
annual inspection and testing by a certified backflow prever�tio�device Yes7er.
(3) 1Vo connecrion exists which would allow the return o�'water used ��r coa�c�ernsi;sg � p ❑
cooling or indus�ial processes bacic to the public water supply.
(4) I�10 pipe or pipe fitting which contains more than�.0% lead exists i�a pz�vate v�iatier � [] ❑
distribution facilities installed on or after July 1, 1988.
(5) 1�10 solder or flux which contains more than 0.2% lead exists in private vva2er � ❑ ❑
distriburion facilities installed on or a�ter July 1, 19�8.
V�later service shall not be provided or restored to the private wate�distc-ibutian fac;l�iies��al�he above condinons are deter_mined to be
in compliance. �
I certify that the following materials will be used in the installation of the priva�?e yUater dis�ibution faciliries located at
L� "1 6 w•v1 �r�ne lU�.�,r�-, and that�e inspector wi1l va?idate compliance dunnb t}a.e inspeciion process:
Service lines Lead ❑ Copper 0 PV� ❑ Other �
Solder Lead � Lead Free ❑ Solvent i✓Veld ❑ Other �
I recognize That this document shall become a permanent record of the aforernentioned Public Water System and that I am]egally
respo �ble for the validity of the information I have provided.
� V � � �t
Signa re of Licensed P1 mber kegistration Number
�a 5� (,0/l 6/I 5
Type of Registration Date
I recognize that this document shall become a permanent record of 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
`J✓hite-Customers Copy Yellow-Ciry's Copy Pink-faspeno�s Copy