2016_0414 '�3`T�l�F��JFP�+��aL,�i•;/E�7';��1?�JTILIiI LJ
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II���9�1�a�fia�� �, �C�o���Prs§�� � T11�?'� �II�kl�b���fl�D��D
I ����id.t,� ���i ��� , upon inspection oc L'ne p�ti-atz �v�zer disiri`uu2aon facilities located at
�'`.S7 e6�w�6�^.� /�//6 fiL" , which �s conaaect�d to �he �Cirij of�o�nell i�%�ter Sys2em, do hzreb;� cercify
that, to the best of my lcnowledoe: _
�+� Non- N/A
Co�npliance �o�pliance
(1) 1`do direct connection between the public dtinYcing wa2er supply anc a po2ennal � ❑ ❑
source of contamiflation exists. �'oiential sources of coniami�ation are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) 1Vo cross-connection bet�.ueen the public drinlciag wa�er su�ply and a private wa��er � ❑ ❑
system exists. Wher2 an actual air gap is not maintained bet�e�n the�ubl'ac v�ater
supply and private v✓ater supply, an approved reduced �ressure-zone bac?cflou�
prevenrion assembly is properly uzstalled and a service agreemenY exists for
annual inspection and testing by a certified baci�flow preve�tion device tes2er.
(3) IVo connecrion exists which would allow the retu�-n o�`water used ior coa��ens�g � ❑ ❑
cooling or industi-ial processes bacic to the public water supply.
(4) No pipe or pipe fitting which contains more than o.0% lead exists i�pnvaie v��ater � [] ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or rlux which contains more than 0.2% lead exists in privace vva7ei � ❑ ❑
distribution facilities installed on or after July 1, 1958.
Water service shall not be provided or restored to the private wa4er disYnbueian iacil�ties�nTil ihe above condicions arz deter_mined to be
in compliance.
I cer�ify that the following m�terials will bz used in the installa�ion of the priva��`e Lvater dis�ibution faciliries located at
��7 �'p�u rh G�.e S !�/ri Ve, and thaY the i�spector v✓i11 va1��e compliance durina the inspec�ion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead � L,ead Free ❑ Solveni�Ield ❑ Other �
I recognize that this document shall become a permanent record of the aforemen#ioned�'ublic Water System and that I am legally
respo �ble for the validity of the information I have provided. .
� � a � �
Signa re of Licensed Pl mber kegistratiox�1�lumbei
a5� Y/ )�l /l6,
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Riblic Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
�Nhi�e-Customefs Copy Yellow-Ciry's Copy Pink•[aspeno�s Copy