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i - ����� ��'� ��� , upon inspec�tio:� �f`�ne p�iti�a7e yvater disiributian faciliti�s ]ocated at
�Go2 �5,..,� �✓i�^►e C�. , which ?s conneci�d to �he �Cit�j of Co��ell Zri�.ter Syster,i, do hereby cercify
that,to the best of my knowledge:
� i�Ton- N/A
Co�pliancz Co;�pliance
(1) No direct connection between the public drin�cing water supply a�d a �o2enrial � ❑ ❑
source of contami.zation exists. Poienrial sources of contamination are isolated
from the public water systzm by an air gap or an appropriate backflo�w prevention
assembly in accordance with Commission regulations.
(2) IVo cross-connecTion bet�veen the public drinking water supply and a privaie wacer � ❑ 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-zone bac?c�lou�
prevention assembly is properly installed and a service agree�nz�Y exists for
annual inspection and testing by a certified backflow preve�tion device tester.
(3) I�io connection exists which would allow the return o�water used for c�ncernsiug �i p ❑
cooling or indus�-ial processes bacic to the public water supply.
(4) iVo pipe or pipe fitting which contains more than 8.0% lead exists in pnvate v��ate� � ❑ ❑
distribution facilities installed on or after July 1, 1988.
(5) No solder or flux which contains more than 0.2% lead exists in privafe vva4er � ❑ ❑
distribution facilities installed on or after July 1, 19�5.
�later service shall not be provided or restored to the private water disYributiar�faciliiies Lnril ihe above condicions arz�etermined to be
in compliance.
I certify that the following materials will be used in the installai�on of the priva4z tivater dis�-ibution facilities loca7ed a2
"`�� (w�h Q��� l.o�r)� and that 2�e inspector wi11 valiclate compliance during 2he inspection process:
Service lines Lead ❑ Copper ❑ �VC ❑ Other �
Solder Lead �7 L,ead Free � Solvent Weld ❑ Other �
I recognize that this document shall become a permanent record o�the aforeinentionec��'ublic WaTer System and that I am legally
respo �ble for the validity of the information I have provided.
� d d �'� �
Signa re of Licensed Pl mber kegistration Number
a5-�er � �l�a> is.
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 1lTumber
Type of Registration Date
LVhite-Customers Copy Yellow-Ciry's Copy . Pink-laspeCors Copy