2016_0315 CITY dF CO�PELT.,�VAT�R UTILITIES
CiI�TaMER SERVICE#1�fSPEC�'].Olti
Residentiai [�" . Cnmmercial ❑ TNRCC ID#057i1040
I p�`"•4• ��°/ �c�F / upon inspecticu�of the pri�ate watez distzihu#iQA faciliriEs lncaced at
�-�.�' �un.�i�v��o�• wbich is connEcfed to the City of Cappell Water System,do hereby ceztif}�
that,ia the best of my knowledge:
� Nozt- N/A
�ompli cs Cornp]iance
(1} No direct cormectian beitiusen the publia dzivking water supply and a potential � ' p p
svurce of oontam3nati.on exists, PQtential sdurces af contns�mination are isolated ' '
from th�public water s�stem by an aur gap or an apprepriate baekfIow preuention
assembfy m eccordauce with Cou�mission regnla�ans.
(2} No cross-connecEian.between the pu6�ic drinking water suppiy aIId a privaie water M1 � p 0
system�exists,��tere an acGsal air gap is not maiutained betweatt the publiC water
snppIy and private water supgiy, an approved reduc�ci pressure-2one baekflow '
, prevention assambly is properly instalied and a s�rvics agreement exists for
annual iuspeetionand testing by a certi�ed bacic#7nrv prevention device tester:
{3) IYo connectian axisLs u�3tich would aIIow#he rcmrn of water used faz condeusing � � �
{ caolmg ar indns�ial pracesses back la the public water suppiy,
(4) Na pipe orpipe f�tii,ng t+�hich corrtains mare than 8,D%3ead exisfs in priv�te wate,r �- O ❑
distributicm facilities instaIled on ar af(�r.July I,1�8$.
{5) Na solder ar flux w}kiah r,anfaius m,ore tha�, 4.2°/a lead exists in private water � �p - �
�lisfn'butifln facilities installed nn or after Juiy I,1�88,
�. .
Water service sha11 notbe providad flr restored to fhe private water disl�'hution faciliries until the ahove eont{itians are detercruned zo be
i.0 compliaIIce.
T ccrtify that the fa3Io��g materials will be used in th�instalIatiun of the.private urater distn`6ution facilities l�cated at
�.�' /�wv7`.� e✓piY and that iha inspec#or�viIl vatidate compliance dtumg the inspectian process:
Service[iaes Leat[ O Copper fl PVC ' [� Q�r �
Solder Lead q L�ead Frca '� Solvent VTe2d O Other ❑
�
I recagnizc tbar this document sk�all bacome a permaneni record of the afore�entioncd Puhlic Water System an�that I am legally
resgonsz-b�for the vaIidity of the informatian T 3aave provided.
��,.-�.-� � � �l ' .
Signature�f Lice � d Plumber Regis�aiiuu.NiunbeF
�'S �"'r .�„4„�o f,�^��ca �
Typa of RegistraTinn �
Date
I.recoguize that�this docurnent shall becotne a pernianent record af.#he aforeme,utiQned Public W atez System and that I am IegalIy
respon�hle far the validity of the infaczuation provizled.
��� ��
Signature o�iz�ector Re�stntron Nttmber
G"�.S' �S' ^�s���
Tygc of xe�istration Date
Whi¢-Custnme�s CuyY VeElow-Ci[)?s Capy Piuk-1¢iP�A�'s CaAY