2015_0417 CITY OF COPPEL;1,WAT�R UTII�ITIES
CUSTOMER SERVICE fNSPECTION
Residential � Commercial 0 TI�iRCC ID#057{3040
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I '' `� "� � `�� ���'`� upon i.nspectiQn af the rn�ata water dis '
� �hut�iA facilinzs loatcd at
��N W�Sfh s,�s.i ' ,which is connecied to the City of Cappelt Water Syste:n,do hereby certify
that,co the best of my knowled�e:
Tn Non- NIA
Compliance Corrtgliance
(Ij No d�zect crnvnectiun between th$public drin{cing wat�r supply and a patentiaI �/ ' Q �
source of conkam.inatioa exists, PQtentia] soure�s of contaminarion are isolated ' '
fram the public Water system by au air gap or an appropriate baekflow preveation
assemb3y iu accordance with Commission regulai�ons.
(2) No crnss-connectian bstween the pubtic drink�g�vater supp[y and a privaie water Cs� p p
system exists,�S�htre an ac�xaI air gap is uot maintained betweea the public watet
supply and grivate water svpply, an ap�rroved reduc�d pressure-zone back#�ow� �
, prevention asscmbly is praperly installed and a service agreement exists for
annual inspectioriand testing by a certi�ed backflazv prevention dev�ce tester:
(3) No connectian exists whieh wbuld allow the return af�vater used for condeusing �/ � D
} cooliag ar industrial processes back to the public water suppiy,
(4) Na pipe orpipe fitCing which contains more than 8.Q%lead exisis in private watez �- p 0
disiributian facilities insialled on or after July I, 1988.
�S) No snlder or tlux w�ich contains more thaA, 4,2°/a lead exists in �ri�ate water � �p � p
dishx'bution facilzties installed an or after Ju1y 1,I938.
... .
Water service shall not be pravided or restored Yo the private water disttibuCion facilaucs until the above conditi.ons are deterAnined to be
iu compliar�ce_
T certify that tUe fallQ��ing materials wiI�be used it7 the installatian of the..grivate�vater distn`buti.on facilities IrScated at
�4 �✓C a f�i 21.P.-. and that the inspector will validate compliance dttring the jnspecrian prpcess:
Service lines Lead ❑ Cogpe� ❑ PVC ' C7 Qtlier �
5older Lead I� I.ead Frea �' Solvent Weld 0 p�� p
��
I recngnize that this document shaIl become a permaneni recard of the afarementioned Publi��Yater Systcm and that I am legally
responsib for the vaIidity of the information I have provided. �
� � trj L
Signature af Lice d Plumber Regisuration Ntunber
��p� y,,, � ��,�-
Ty�e ofRegisirafion Date�—
I recogsaize that•this document shall become a pecmanent recard af the afflrcmenrioned Publi�Watez System and that I am legally
respon ' Ie for tlie validity of tEie infarrnation pruvided.
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Signa[ur��'I�ectar Re�istration Number ""�—
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Type �f Re�istrat3on • ..__ Date
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