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3 ��..��i� ���i��� , upon inspec�tio� �f�t�e p�vate �vate�distri'�u7ian faciliYies loca2ed aT
��6� ��T ('�• . , �vhich is cflnaect�d to �he City of Co��el] zsia.ter Syster7, do hereby ce�ify
that,to the besY of my knowledge:
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Cor�plia�ce Co�pliance
(1) IVo direct connection between the public driz�cing wa2er su�;�ly anc a po2ennal � ❑ p
source of contamilZation exists. Poiential sources of coniamination are isolated
from the public water systzm by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) No cross-connection betvveen the public drinlcing waTer s�apply and a private wa�er � ❑ ❑
system exists. Wher�an actual air gap is not maintained betr�een the public water
supply and private water supr�ly, an approved reduced pressure-zone bacic_�lou-
prevention assembly is properly uzstalled and a service aggezme�Y exists for
annual inspection and 2estin.g by a certified backx'low prever�tian device tes2er.
(3) No connecrion exists which would allow the return o�water used foi co�ac�eras�g � ❑ ❑
cooling or indus�ial processes bacl�to the public�vater supply.
(4) 1�10 pipe or pipe fitting which contains more than 8.0% lead exists ir�p�va�e v�aYer ,� [] ❑
distribution facilities installed on or after July 1, 1985.
(5) I�10 solder or rlux which contains more than 0.2% lead exists in privaYe water � ❑ ❑
distriburion facilities installed on or after July l, 19SS.
V�Iater service shall not be provided or restored to the private wate�disYrib�!tiara iacil?�ies Ln�il�he above c�ndicions are detern�ined to be
in compliance.
I certify tha2 the following materials will be used in the installaiion of the priv�?e�Uater dis�ibution faciliries]ocated a4
7� l �(7(i� .Spf��'�(� �e'� and ttiaY 2he i�spector wi11 vaiidate cor�apliance during�the inspec�ion process:
Service lines Lead ❑ Copper � PV� ❑ Other �
Solder Lead rJ Lead Free 0 Solvent�Veld ❑ Ocher �
I recognize that this document shall become a permanent record o�`the afoiernen2ioned Public�hlater System and Yhat I am legally
respo 'ble for the validity of the information I have provided.
� 9 � ��, �
Signa re of Licensed Pl mber kegistration Number
��5� �/�r� ��•
Type of Registration Date
I recognize that this document shall become a permanent record of the aforementioned Public�Nater System and that I am]egally
responsible for the validity of the information provided.
Signature of Inspector Registration Number ,
\
Typz of Registration DaTe
tNhite•Customers Copy Yellow-Ciry's Copy Pink-Iasperto�s Copy