2016_0302 c�TY a�cop��L�,�v,�.r�r�u�zTZEs
CiJSTL3MER SERVICE�I�1�PECTIOlk
Residentiai � Cammereial ❑ TNRC�II1#OS7{l04D
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� �' upon znspecti�n of the grivate wa[er duaibutiau faciliriEs 1Qcaced at
J� �, �
'S' ��� ,whickz is conuacied to the City o#'CappeII Water System,do hereby cez#iC}�
that,ta the hest of my kttpwledge;
� Non- 2�IA
(I} NQ d'zrecf connectian betw.e�n Yhc public d�i�iAg water supp?y and a patential �m�ce Ca�Iiance
source of contamivation exisrs. Potent�al souress af cantauzination a.re iso]ated ' �
from the public v,�aker system hy an aff�ap or an appropriate baekflow pzeveatiott
assemb3y in accozdance with Couunission regvlatians.
(Z} No crQss-cozulection between the gubIic ctr�nking v,�ater supp,[y and a privafe vrater �'' p �
system e�ists,�tii�here an actu�.l azc gap is natmaintained between khe public•water.
suppIy and grivate water sr�pPlY, an approved raduced pressure-zone backflow �
. prevention assembly is propexly insialied and a ssrvice agreement exisis for -
annual iuspectionand testing by a certi#ied bacic#]ativ pretrention device tester:
(3) F+lo conrtection exists whiclt wa�s3d aIlaw#he returri of water usec�f�z cnndensin� �/ 0 �
{ cooI'mg or'sndus�zal processes back to the pnblzc�vatsr supply,
�4) Na pipe arpip��itting urhich contaix�s mare th�w 8.0%�ead exists in przvate water �- C7 Cl
distribuaan facilities instaIled on or after.xuIy I, 1988.
{�) No solder or flux w�ich confazns more than 4.2°/a lead exists in �ivate water � ' p _ �
distn'butionfacilitirs insialSed an orafter July 1,1�8$.
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�HtCI SSSV2Ce&�13�FfOt�}G FTLSYI�Cd OX ICStOrBt��4�1C�3I]V1fC SYBtCT�iStTlt3lIfSOII fHC77.l�CICS 12ri��1C�OYe COIIf�lCi.0115 3.tE CiCtCITR2Aed tD�5e
ITI COIII�7II3TIC@. .
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I certify that tbe folI4s�-ing materials�ril]be used'ur the installatiau of the private vsrater dism`bubion faciliries Idcated at
cir�i� �CC✓�� aad that the inspector wil�validale comp]iance drtring the�zspectian process:
Service,lines Lead D Cogpee ❑ PVC ' C� Qtlisr �
5older T.ead C? X,ead Free � SoLveat Weld Q Othec Q
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I recoo='e that tbis docvmant sh�il become a pezmanent recard of the aforemeutioued Puhli�Water System an�that I am tegally
r�spons for the vaIidity ot'the infarrnatian I e provided.
� ��
Signature a ce d PI ber Regis ati'on,NtunbeF
�'`�s�`�._ 3 Z�a`�
Type ofReg�strahan Date
i recogxtize that•this d�cument shalI became a pertnancn.t recaz� F�e aforementioned Publi�Watez System and that T am fegally
r�spon�jSIe far th �lidity af tlxe�ormation pravz
' �d�
Signature of1 ector Re�istra#inn Nt�mber
�c.I s PS .� .
2—,��6
Tygc of Regis�ation Date
Whi�c-Cussomcf�Cupy YaElow-Cit�s Copy
Piolc-InsP W cfs CnPY