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��� � �czo.�ar � � . , dvnich is co��ect�c] �o Lne Ci�� of�'oN�e11 ji�i�ter Syste��, d� hereby ce�i;fy
�
ihat,to the best oi my l��o��led�e:
�-� �1on- �i/A
�Co=_npl;a�c� Co��lia�ce
(1) TRTo dL�ect connectio� beT�✓een the pLblic drinlcing wa4er s��;�ly �Q1C1 a �oiy�iial � � ❑
source of conta�-nination e�is�s. �oten�ial sources of coata_-ri�anor� are isolated
from the public water systzm by an air gap or an approp=iate bac,�flo��p=eve�tion
assembly in accordance with Com��ission regulations.
(2) I�10 cPoss-connection bettiveen ihe public c�rin,'cing dvazer sui�ply a.nd a p�vaie v�ia��r � ❑ ❑
system exists. Whe:e zn actual air gap is not mainiairie�t�e�een i�e�u�Iic water
supply and private w�.ter supply, an approved reduced pressur�-zo�e bacic�lov;
preven�ion asse_mbly is properly i.nstalled and a ser��ice aaree�z�ati ex�s�s ior
, annual inspection and Yesti?�g by a cer�ified bac�'�obv prevea_ion device��sre�.
(3) No connecrion exists whic� would allow thz reiw� of tivater used io= c��c�e�sa�g � p ❑
cooling or indus�ial prs�cesses bacic to the public v�ater su��dy.
(�) No pipe or pipe fitting�,vhich contains Tnore tha�°0.0% lead �xis�s ir_pr�v�ie 1��a'tei ,� [] 0
dist�bution facilities ir.stalled on or after 7uly 1, 1980.
(�) I�lo solder or flux which contai�s rnore than 0.2°/o lead exists in p�ivate dvacer � ❑ ❑
distribution facilities installed on or after July 1, 195�.
�Ia�er se��icz shall no2 be provided or Testorrrl co the priva7�w�ie�dis'rributiicn s�.c;l?iizs L.nti`�e a'oove co�di�c�s are e�ete��i�ed�o be
in compliance.
7 c��ify tha2 the follo�vino�aterials v�ill�z used in ihe installatio�of 2he p�i�i�?z tivate�dis�ibutian facil_ines located ai
�'�`�, I._e.����,.�;q � � . and�ar tne i�s�ec2or v✓il�va1;��e cor��plaa.a�ce dunng��e ir_spection p�ocess:
Seriice l�es T ead ❑ Copper � �VC ❑ fl2her �
Solder T ezd � I,ead F'ree ❑ Sol��eni j✓Veld ❑ �ther �
I recoo ize 2hat ti�is document shall become a;oe�!manent record o_F t'ee a_�orv�en�tioned�blic��Vatzr System and ihaT I an legally
respon �ble for the validity o_F the in_formation I have provided.
� � � � � �
Signa re of Licensed P1 mber kegistratio�Number
���5� �� �,�f ���'
Type of Registration Date
I recognize that this document shall become a permanent record oi the aforementioned Public Water System and�hat I am legaily
responsible for ihe validity of the inierriation provided.
Signature of Inspector Registratior.i�lumber
Typz ofRegistiation Da4e
�l/hi(e-Customels Copy Yellow-Ciry's Co�y . Pinh-laspeaofs Copy