2013_1031 Re�fdenti�l � Commerci�l ❑ TN�tC� yl��►DS70040
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� _ �_„ ,upo■ �nspccqsn�f the,pn ate at�r d�smtiutrou fic�lines l�c.ted a�
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j eZG _ (2GS,L�(L��g� C� .v�rt�ich is cotu►cct�d to Ehc City of Cappcll Wator Systcm, do hcrctay ctrtity
aat, ta thc bcst of my know�cdge:
I� Na:,. 'N/A
Go p �atict Gompliance �
!) Na �dreect cannrcti+�n batwccn the pubfic drir�ktt�,� w�ter sup�3y �t�d s potenti�l ❑ p
srsutce o�`c�untamins#ior� exists. Pettr�tial sourcea uf c�s�tami�ation are isotated
f�am th�pub�ic w�a�e�system by an;.�ir gep cr�sp�ropriate backf�ow prevantina
asaemh�t�ir1 accordance with C�uu�tt�ss��►t�r��utatians.
�) No�ross-ew�r►►ec�ian betwccn t�c pnblic drinki�g ureEer suppl�► and a pzivate water �.� C� p
syxiem ex�sts. �here en actttat su���i�nat maints�ted between the public w�ter
s�pply atid ptiv�te watet supgly, �tn a�pproved reduccd pressu�+c•zonc backfIoKr
pre�tt�tian gssemb1y i� propetly inst�lled az�d a service ag�eement cxists far
annu�l iuspection�rtd teating by a ccrci�ied bacicft�w�reve�tion devicz#ester.
3� No conneckivn exiats w�ich would aticw the retuxn �f�vstcY t,scd foz,eot�dcnsirig � Q p
caoli:�g or in�ustriat psaczsscs bac�to the pu�lic �rater supgly.
4} No pigc or�ipe f t�i�g which co�ra�►a nwre th�u 8.4%]eed=ausls in private w�ter � � L]
dist�ibution faci�itus instatled on or after 7vty 1, 1988.
5) Na solder ot��x which coni'aen� more than 4,2°ra lead exi�ts in private wafer p ❑
distribtt�i+�n feCi�itiCs���a�1ed+�tt vr�fter July 1, 1988.
�ater scr3ricc s�ll not be pravidtd or restared to�h�private water distribvti+an�acrtities unri{the above canditioas arc d�t�ad to i�
n carnp3ia�cc.
cs�tify that the fo�t�wing rtiateri�ls�i!!'��ua�d i�the inalalfation af thc privatc wattr distributi�a f�cititi�s iocetsd at
� �� ���f�f��A�.l� �� and t�at th�ine}�ect�r w�l�v�li�tc+�ompliarsce dw�ng t'hc i�spe�tian ptvices
ieryice tines Lrad C� Copg�c PV� fl Dther 13
►v�der Lead CI Lea�l Free Solvent Weld fl Other L7
rc�ogr�izc that this dacurnent sha11 bccvrnz a permenent record�f�he afnrementioned Pub}ic'Watcr System and that�am legaliy
cspo for t�e vzlidity�f ' iarmation 1 havc provided.
� l,��f��� /
iigtta xe of Lt�ct�sCd Fl Yti�bGr , �kcg�svarian N�m�r�
Q ��. G�,�L'L C��_'/�-� �d f
f�rpe of Registrati�n Date
r�ca�izr t'�at�his document sha11 become�per�nene�nt rtcocd of the aforementioncd Pub�c Water Systsm and t3set I am legally
espar�sibk�'or thc va�idity oi"the u►�o�stion pravid�d,
�ig��ture of Inspector Rcgistr�tion Numbcr