2014_0821 CITY{1�����IELI,WAr"T'L�R U'I'ILI7'IES
�USTU3VIEI�S�RVX�E�!�`SPECTIfl1ti
Resi�i�rtial �' €;crmn��rci�i C] 1'1�1RCC I3)#057QQ�40
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1 l�"� �•J'-`` ��� ��=€�. t';� ,upa� ins�ecEiuc�af tthe priv�te water tiistrit�utit�� f�ciIities Icac�t�d at
y (�2—Q ��-'��� ,wkich is connected�a the+�ity vf�op��ll Water Systcm, d€�hereby Gerti�'y
t2cat,ta t11�besi of my knowIedge:
� t+Isan- A1fA
Complia�ace ' Cornpliance
�2) N� dire�t connectian betwe�n the public drinking water sapply aud s potentiAl �'` ' CI C�
s�uac� of c�nt�mination exist�. Pc�t�nti�l sources ��'coniamination �x� i�t�lat��i .
from the public w�ter system by an air g�p ar an apprc+print�b�ckflnw pr�ventinn
assembly ua accord�nc�with���z2ussi��reg�ila��ns.
��� l�t�crass-conn�ctit��b�tweeaa khe public+3rinki.ng watcr sup�ly az�+i a�private w�xer �''" C� CI
s�lstem exists.� V►�er�an�ctu�I aiz gap is�t�t rnaintaz�ed between tt�e publie wa4er
supply �d privat� water supplY, an appraved redt�ced pressure-zone b�ckfl+�►��
prevention assembl� i� properly i�stalled ac�� a service �gre�men� exi�ts for
annua�inspec�ion gnd tesiirig by a c�ztifi�d b��tcflow preues�tion dcvice test�er.
(�� Nt�ccannection exists whi�h would allc�w fh�retum t�E'water used for ce�ndex�sian�t �''� � [}
� coolim�az�ind�ustrial psoc�sses back ts�t3��pu��ic wa�er suppi�+. �
(4} I�Sc�gipe or pipe�ttiit�g which c�n�a'tn.s�ore tt�au$,0°/'n lead�xists in private w�te:r �,Y° Cl �l
distrzbutian facitities insG�lI�d fln�r after�Tuly I, 19$$. .
��j N� stiic�er or flux which cont�ins morc. than �,24f� l�ad exists in priv�t� waier � Q , , �
dzsi�ibutiqn facilitie�i�stall�i t�n ar af�r 3uly 1, 1���.
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Water servic�shall not be grovid�d�r restosed ta the pravate wa�e�c��siribwtian fa�iliti�s unril the�bQve candikions are determined ta bc
�cs compliance. �
I certify tliat tt►�fc�llowin�materisls wil!b�us�ci iu t���instaliatian of the�rivate watex disuibuNoa fscilitics Ibcated at
_��i_d. �����9� �cad th�t the inspector wi11 v�Iidate compbiaucc d�g th�inspection process:
?5ervice tir�e� Lead � Gcap�ter CI PVC ' t=l Other ,,�.
�alde Lead Cl Lead Free � Satve�t�eld � C?ebet �
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I r�co�niu tMat thzs dacucnent shall�becc�nr�e�pesn��ent re�c�rt�r���h�afc���rri�ntzv�ed Public Wak�r System and th�t I�rz�le�ally
r�sps�a��i�l�for�ths v�lidity�f the in�ormati+a�I h�v�e grovid�d,
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Si�n�tur�:af Lice � d Plumler l��gis�iation��l�iu�b�r .��.�.
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°�;�rp�a�"Registratian I�ate '�
S a�ec�grsiza tliat this dc�cument sh�11 becc�me a permanent r��ord�+f t}�c afQr�met�tiar��d Pu�alic W�ter Syst�m and that I am l���lly
r�s�+�n�a�le fnr the validity of tM��€orma�ion ps�avicl�c3.
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Sign�ture of�� pector � �.e�istraku�n Nurnber �
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Typ� afR,e�is�aCion � Uate �
t�'hiia-Ciuwmcr't CupY Yellaw.City x t�uPY Fuik•1nspF aor'z Co�y