2016_0504 ��l�'�JF,��GPp:+�i I.?,��f�'T;f��?�J'TIL3;1 i�S
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l[���Am���Qfi�d �I„ r'La��r�n��rs��� � T1I��'�ID ��D����D9D
7 ��'`���°i� ���i��� , upon �nspectio� oi tne p�ti��te zv�ter dis�-ribuTaan facilities loca4ed at
lq S� �I�ir� Y�he. (�-. , �vhich ?s co�.ected to �he Ci�� of�a��ell Z��Jater Syste�, do hzreby ce�'iify
that,to the best of my knowledge:
�� Non- N/A
Co�pliance Co�nplia�ce
(1) ]Vo dieect c�nnection between The public drin.'cing waYer supaly anc a potennal � ❑ ❑
source of contamination exists. Poiential sources of contarnination are isolaeed
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
(2) 1Vo cross-connecrion be�,veen the public drinking wa�er su�ply and a privaie wa�er � p ❑
system exists. Vdhere an actual air gap is not maintained bet�veen the�ubiic s✓ater
supply and private water supply, an approved reduced pressure-zons bacic�lou�
prevenrion assembly is properly installed and a service agree�znt exista for
annual inspection and 2esYing by a certified backflow prevention de�ice tesrer.
(3) No connecrion exists which would allow the return o�`water used foi coa��ensing � p ❑
cooling or industrial processes bacic to the public water supply.
(G) 1Vo pipe or pipe fiTting dvvhich contains more than 8.0% lead e;�ists in p�vaie u�aYer � [] ❑
distnburion faciliries installed on or after July 1, 1988.
(5) No solder or i'lux which contains more than 0.2% ]ead exists in private vvater � ❑ ❑
distribution facilities installed on or after July 1, 1988.
V�Iater service shall not be provided or restored to the private water dis2rribu�ian iac�l�iies��-il�e above condi'rions are�eter_mined eo be
in compliaace.
I certify that the followin materials will be used in the installa�on of the priv�te�,Uater dis�-ibution faciliries located at
��� C��� �+�C C�� and ttiat Y�e inspector will valiclate compliance dunab the inspecrion process:
Service lines Lead ❑ Copper ❑ PV� ❑ Other �
Solder Lead rJ Lead F'ree ❑ Solvent�Veld ❑ OYher �,
I recognize 2hat this document shall become a permanent record o�the aforerrbeniioned�"ublic Water 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
a 5-� ..SI K �/�
Type of Registration 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 T�egistration Number
Typz of Registration Date
9+�hite-Customers Copy Yellow-City's Copy Pink-IaspectoYs Copy