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2013_1031 �esldenti�l � �ommer�i�1 � T1V�tCC �1�#D570040 � J �`h���v� ,t�so� iaspectian v�f th���ivate water distributio�fa�ili�es bcated a� ,wh'rch is ct�nnected ta th�Ciry oF Coppcll watcr System, d�hcr�by�or4i�'y� S�t,to thc bes�at'my knvw�edge: I� l�ion- N/!�► C�mp �ance Camrptisace � I) "N� direct conncctit�� b+etwccn xh�pu�lic �tkircg wst�r s�p�rly �nd a �otcnti�l C3 p �o�rrce of ct�ntaminatio� exist�. PotertiEiat sources of c�n#am�atian are isolated horn t�r p�btic water systerri by an.air gap�x�apprapri$te back�tow preve�tion �ssemhf,�xr►accordancc wiih Comrnissi�n reg�,�ations. - �,1 1�o cros�-conneclion betaraca tt�e pub�i�dt't�iking wator suppl��nd a prius�e water �� p p sp�tern cxfsts. Wher�et�ach�al au ga�i i��oi m�i�tained betw�en tl�e public water suppjy ans� priv�t� w8ce� s�pply, a� apprvved �cduccd pc�ss�rc-z�ne ba�kflov►� prtvt�Ei��t es�ert�bly is properly it�s#al�ed and a setvice agteemen# eXists fvr a�nual ir�pecti�n a��d testing by�ccrri�i�d backflQw prevegt��an device t�ster. 3) I+ic�conneckion exists which wou3+d ailov� khe retum nt watcr t�scd for cot�3cnsi�g '�] [3 p �a��is3g ar indt�siri�t proccssts beck tu the p�blic wat�r sugp2y. �'� 4� 1'+�o pi�or p�pe�i�in� which ca�tain�mo�e then 6.4°�lead exis�s in private water � ❑ ❑ distribui�a�r f�iliries instalted an or after���y t, i988. 5} �+Io sold�r c�r flux which cont�is�s m�rc t�an Q.2°l� l�ad exists in �Srivate water p � dlstribution f�cilicies instalied on vr after�uly 1, 19�8. �ater service aba�I noa 6c prov�dcd or restored to�he pri�rate urater dis�ribution�aci�ties unci�the�bave cogditions are dctr.rmined to b �cornpliance. - �cnt�I t�at th ullawing rnet�r�et�vvili be used i.n the it�sta��sticu�f d�e pniv$tc watcr distribution�#'aci�itics Ic�ceted at ��� r��-- aad that the inspectvr will validate campliance dtuing#he inspcctivn proc�es ;$ � � P Lead C1 Capper PV� �3 Ot�aer �3 �o}der Lead �] �sad Free Solvant Weld tJ Cit�er � r�eagn�e that th�s docurn�nt s'hal�becomc a pczmsn+e�t recc�r�!Qf thL a�'n�em�ntioaed Fu�alic W��er�yst�rr���d ch$ti T am tegatly cspo €or t�te valid�ty o€ ' formation I hsve�rflvidtd_ ��r�. -���� � R�gne e af Licens�Pl rr�ber . , Rtgist�at;on�TunnbcF � (� �'�- ��C�L���—� �� f '`y�pe of�tegistrati�n Date z�cogn�ze t'hat thi�d�vment s��f�bocarne a g�snt�nt r�cord a�`thc aforernentio�cd Asbli�1�►�aer System and�at I er�kgally espoztsibl�fa�the v��`sdity Qf the iri�Q�rnation pr�vidcd. ;ignatwe af Inspe�tor Rcg,stratioa�Ntunbcr