Untitled (57) C1TY OF COPFELL�VATE12 UTILITIES
CL]STOI�+IER SERVICE fN�SPECT1014
Residentiai f,�" Commerciat ❑ TNRCC ID#0576040
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I f i `��'� �r'"�' ���`� upon inspectic�n af the private waEer distzibu#iou faciti�ies 2ocated at
— ��� C(,�srJ�f��V�� ,whickt is cflnnecled to the City of Cappell Water System,do h�reby certiCy
that,to the best of my knov�Iedge:
� Non- T�t/A
Campliancs ComZrliance
(i) No duect cannecuon between thc publia drinkiug wat�r suppIy and a patential �J/ ' p ❑
source of cosstami�ation exists. Potentia,l sources af contaminatioa are iso]ated ' '
frQm the public vt�ater sys#em by an air gap ax an apgropriate backflow preueatian
assemb3y in accordance with Commission regula4ans.
{Z) No cr�ss-connectian bstwcen the gvbIic drinkzng watcr supp(y and a privai�water f� p p
system exists,���There an actua.l air gap is not rnaintained between the public�rater
suppIy and grivate water s�pply, an appro�ed reduced pressure-r.one baekflow �
, prevention assembly is properly insTalied and a service agreement exists for
annual i�.speciionand testing by a certifed back#14�v prevention device tester:
(3) No connecrion exisis which wou7d aIIow the return af water used£ar condensixa� �j/ p �
S cool"mg ur'sIIdustrzal process�s back ta the public�vater suppIy,
(a) Na pipe arpip�fitiing vv3uch eontains more than 8A°!o lead exists in privete water �• p p
dis�ibution facilitics installed on ur aft�r.J'ufy I, 1�88. ,
(5) No solder or tlux �v�ich confains more tf�aw, 42°/a lead exis�s in �srivate water Q/ � p � p
distn`but�on facilzties instal�ed an ar after July 1,I988.
.. •
Water service ahall natbe pravided or restored to ihe private water disttibuiian faciliues until the aboue eanditi.oas are deter�nznad to be
in compliance.
I certify that the fu3lowing materials wi116e used irx the instalIation of the privace watez discn`bution facilirirs Idcated afi
and that the inspector will vatidate complianee deuing the inspectian pracess:
Service liries Lead O Coppe� ❑ PVC - p pti�er �
5older Lead q X,ead Frea �` Soi�ent Weld U Other ❑
r
I recognize that this dacvrnent sha11 beeome a permaneni record of the aforementioned Pt�blic Water Sysiczn and that I am Iegally
r�sponszb for the vaIidity of the information I have providad. �
,� � �
Signature af Lice d Plumber Regist=ation�Number
�.�P� , ._
Type ofRegisirarion Date
I.recoguize that•this document shall become a permanent recazd of the aForemeurianed Public Water 5ystem and thai I am legalIy
r�spon ' le for tI�e validity af the iaformarion provided.
��.�
Signalure of I pector Registzation Number
�N� S �f �-/
Tyge ofRegisti-ation I?ate
YJhi¢-Cus[amoh CupY Yalkow.Cit>?s Copy PioSc-Iespedofs CapY