2015_0213 §Zgp.�7(�� ,g,Ppendiac #). Customer Service Jns�ection Certification.
�'xgure: 30 TA� §29(1.4?(d)
Customer Service Inspecl3on Cez#i�eate
Q� Ql � i PW� I.D.#
Name of FVi�' --__..
Location of Service ��t -'
�___ _.-_..__�.
; Reasan for Inspecdon: .............................................
�AIew construction........................................ ��
v�here contarninam hazacds are suspected ....................................�
�Existing service ` - - - ,_ _ -
�Majar r�novation ar.e an�ion of disuihution faciiities ......:.......:...�..__...__._.�..�...,�__ �
I ,.�- -
� ,� ;i'���.� r upon insp�[ian af the privat�wat�r disirib�etion facilities connect�d co the
aforemer►titsned pubiic water sugp�y_do he_reby_certif� chat, to the besi of my icnowled�e:___-_------ ,
, - -- ----
_ _ . _.
�Com liance Non-compliance _:.-r - . .._. _ . - .
, �
p 1. No direct cortnection becween t�e ptiblic dr'rnking waEer supply;
and a patential source of concamination exists, Poten6al saurces�
' of cvnta�inacion are isQlat,ed from the public waEex syste►n by an�
' � � or an appropriate bacicftow prevention assernbly in i
acc�ard�a�with�omm�ssion regula�ions., _ -- �
- - --
_ , _... - �
� � � �, . _ N+a cross-aconnec�on between the public drtnking wa[er supply!
and a pnvate wat�r sysc�n ex�scs• Wbere an actual air gag is not
�A�i��r�the public wacer suPP1y and a private water�
� �FP�Y, ��PPT'�ved recluced pressure-zone backflow prevenaan
'� assembly is properly insiailed ar►d a service agreement exists for
annual inspection and testing by a certified hackflaw preventianl
� assembly tester._ --== _------- -__..:.
� --- ------- ----------.�_ ---------=--_'_ �
_. _ -- ---- .._
-- �-_____�_----
; p 3. No connecaon ex.ists wiuch wauld allow the retum o water use
__ �_ � for eondensin;,cooling or ir�siusuial pracesses back to the public i
i water su 1 .�_�______-------.._._�_�--�
P�Y�_ �._. -_ -
-- --->----==_-____ -�-�_�
-----__---�--___
,.___� --. -.
p 4. No pipe ar pipe f�tting whieh cantains mare ttuw$.0°�lead exists
}A privaie wat�r distribution facilitees installed on ar after July 1,
, 1988� --- --`��--__._ -
��_--- --. - ---___,._�_Q_______-'-��_._�_ I'�To salder ar flux which contaizns more ihan Q�9b lead exists�in�
� Y �
private wa€er distribution facilities installed on or after 3uly 1,�
1988._ - ----- --
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_ __ --- •
._. _ __. . .
_.. ,
I further ce�tify that the following[naeenals were usecl in ihe installation af the_gnvate_water distnbut�4n ac�i �'
- - --- Dther 0�
_ - - -- Q
�Service lines Lead � Copp,�r �_ PVC - '
�.ead Q Lead Free_ �tvent V+field 0 ____ Other--i7__---- -
°Sold�r ____ _._.__ ----- --- �-�--_._�_.A _____. �.
�i �'ecognize that this d4cument steali become a perrnane�tt neca�r+d c�f the afot-�mentioneci PuhIic Water System an d
that I am legally responsible far the validity of the inf�rmation I have grovided.
Remarks:
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Regiscration Nur�t�er
Signature af nspector
j;�,� �-�a�. ��S;E.r'� �Jc�u (',v e�/�
a
Title Type�f Reg�sstraiian
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