2016_0504 �3'T�l DF����PP���;L?�?�t�7'rR TITILI d���
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]F���s�1�n�a�� �I. �rt��r,n��rs�a� (� '�I'1�i3��ID k'�95�fl��4�D
T �����✓� G��� ���� , upon Lnspec�tio;� of tne p�:��t� �va?er dis'tributian iacilities located at
76 I Ree.� S�bfk`nU f� . , �vhich �s conneciecl ?o �he Ci'ty of�9��e]j �;1Jater SysTefn, do hLrtiby cercify
that, to the best oi my knowledge:
�� Non- �T/A
Co�ianc� �oaaipliance
(1) IVo direct connection between the public drin.'cing water supply and a �o2en�ial ❑ ❑
source of contamiaaation exists. �oiential sources of con2amination are isolaYed
from the public water system by an air gap or an appropriate backflolr✓prevention
assembly in accordance with Commission regulations.
(2) No cross-connection beriveen the public drinlcing water supply and a private vra�rer � ❑ p
system exists. Where an actual air gap is not maiBtained between the public v✓ater
supply and private water supply, an approved reduced pressure-zone bac?��lou�
prevention assembly is properly installed and a service a�ree:�rie�aY exisfs for
annual inspection and YesYing by a certifed backflow prevemtian device Yes2er.
(3) No connecrion exists whicn would allow the return o�F water used foi c��c�er�si�g � p ❑
cooling or industrial processes bacic to the public water supply.
(4) No pipe or pipe fitting bvhich contains more than 8.0% lead exists in p�vate vvaYer � [] ❑
dis�iburion facilities ins2alled on or after July 1, 1985.
(5) No solder or rlux which contains more than 0.2% lead exists in �rivar� vvater � p ❑
distriburion facilities installed on or a�ter July 1, 1988.
Vlater service shall not be provided or restored to the private wate�distributian facil?ties Ln�il the above condicions are detemiined to be
in compliance.
I certify that the following naterials will be used in the installa�ion of the priv�'!z�UaYer dis�-ibution�aciliries located at
76 ( Roe� `S/�!'�►�i�' rG� and that�e inspector v✓ill validate cor�plia�ce durina ihe inspecrion process:
Service lines Lead ❑ Copper ❑ PVC 0 Other �(
Solder Lead ❑ Lead Free ❑ Solveni�Teld ❑ Other �
I recognize That this document shall become a permanent record o�`t�e aforeinentioned Public bUat�r System and that I am legally
respo 'ble for the validity of the information I have provided.
� � d � �
Signa re of Licensed Pl mber kegistration Number
a5� 5/ H I I 6,
Type of Regis�ation 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 p�aq�
�A'hite-Customers CoDY Yellow-City's CoAY� Pink•Inspeaofs Copy