2016_0000 �33 �i�je ��
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I ��,�L,�(�id�' ���i��� , upon ins��cYio:� oi`�ne. p�iti�ate tiv�ter dis�i-i5uT3an facilities located zi
�''�1 ���� �.. , dvhich ?s cor�eciecl to the Cit�j of Co�;�el] i�1%ater System, do hereby ce�iify
that,to the best of my knowledge:
3n iVon- �1/A
Compliance �o�pliance
(1) 1Vo direct connection between the public drin:cing wa2er sup;�ly a�c1 a po2ennal � ❑ ❑
source of contami�zation exists. Poiential sources of coatamination are isolated
from the public water systzm by an air gap or an appropriate backflotiv preven�ion
assembly in accordance with Com�nission regulations.
(2) 1Vo cross-connection beriveen the public drinking water supply and a privaie war�r � ❑ ❑
system exists. Where an actual air gap is not maintained bet�,veen 7he public water
supply and private water supply, an approved reduced pressure-zon� bacic�lou�
prevenrion assembly is properly i�zstalled and a service agreement exists for
annuai inspection and tesring by a certified backflow prevention device tester.
(3) No connecrion exists which would allow the retw-� o�vva4er used for conc�erns�g � p ❑
cooling or industrial processes bacic to the public water supply.
(4) IVo pipe or pipe fitting vvhich contains more than 8.0% lead exists in p�vate waYei ,� [] ❑
distnburion facilities ins4alled on or after July 1, 1988.
(5) No solder or r'lux which contains more than 0.2% lead exists in �Orivate �vater � ❑ ❑
distribution facilities installed on or after July 1, 1985.
�/ater service shall not be provided or resYored co the pnvate water clistributian faciliiies Lntil�e above condicions are deter_mined to be
in compliance.
I certify that the following materials will bz used in the installation of the priva?e water dis�-ibution faciliries located at
T"L"'� �,..+,...�.� *.,, d �..,,` �`� � and that�e inspector will vaiiclate compliance during�the inspec�ion process:
Service lines Lead ❑ Copper ❑ �VC ❑ Other �[
Solder Lead !7 Lead Free ❑ Solvent Weld ❑ Other �
I recognize that this document shall become a permanent record of the aforementioned F'ublic�iVa2er 5ystem and that I am legally
respo 'ble for the validity of the information I have provided.
� � � �� �
Signa re of Licensed Pl mber kegistration 1\Tumber
�0�5�
Type ofRegistration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration Date
LVhiie-Customels Copy }'ellow-City's Copy Pink-latpenors Copy