2016_0407 CITX�F C{?pPELt,WAT�R UT1LiTIES
C�3STOMER SERVICE#NSPECTIOlti
Residential [�'-' Cammercia! ❑ T3KRCC ID#a57U04D
I �"�� ,�C � upon inspectic3n ef tha grivate wa[et distri6v#iab facilitiEs locaced at
_ wbzckz is cnnnected to the City of Cappell WaY�r System,do hereby ceztify
� that,Ea the best of my knotvIecige:
� � Non- NtA
CampIiance Camp]iance
�I� ND [IaICCt Cql1Z1CCUa51�3ChYCCR Y�78 i?UI3I1G drinking water suppiy and a potential �]/ ' Q p
source of cantamivati.vn exists. Pofentia] sources af onntamination are isolated ' '
from the gublic water s�stem by an air�ap or an appropriate bacIsfIow preverrtiou
assembly�accoxdance with Commission r�gulations. ,
(2) No crnss-connecti�n between fhe gu6Iic drinking water supgiy aIId a privaie water ry � p p
system e�cists,�Where an aetual air gap is uo#utaintained between the public watec
snpply and grivate water su,pply, an approved reduced pressure-zone hackflow �
, prevention asscmbly is prnperly instalied and a ssrvice agzeemen.f exisLF for
annual inspectios�and tesfing by a certifed back#7nt3+prevention dev�e tester.
(3} No connecfian exists which wouId aIlaw the retum of water used fnr condensing � p �
i cnnImg ar sndns�ial grocesses back to the publie�vater'supply,
{�F) Na pipe arpipe fitt�ing which carrtains more than 8,0%lea�,exisis in priv�te water i�' • p CI
distributian facilities installed an or afcer.JuIy I,I�$$. .
(5) No solder ar flux w3zich coufains m.ars than 42°/a lead exists in �ivate water � , .p ,. .. p
distdbu4on facilities instzl]ed an or after Ju3.p t,1�88,
*, .
Water service shall not be pravided�r restored to fhe private water disitibufiion faciJi,dcs until the aboue conditiaus aze detenmzned to be
zn comgliancc.
I certify that the follou-iRg materials will 6s used iu the ittsfallati�n of the.private water dism'bution faciIities Idcated at
7.�� �nJi iefo�c _aad that the inspector�vi1�validate�ompl�ance dcuing t3ie inspecrion process:
Service lines Lead O Copper ❑ PVC ' ❑ Ot{�er �
Solder Lead ❑ x,ead Frea � Solvent Weld Cf Othcr ❑
a
I recognizc that this document shall become a pezmaneni record of Yhe a:farementioned l�bli�Water 3ystem and thai I azn Iegally
respons��for the valzrlity of the informatian I havs provided.
� �l� .
S��na�t re af L d Plumber R�istraiw..a.N'umbeF
�✓.7�'� a .._
Typa ofRegistrafian Date
I recoguize that•this doctuiteni shall he�ome a pecmanent recard of.#he aforementinned Pu�li�Watez System and that I am legalIy
r�spon�ij'ile for tfie validity of the infacination pravid�d.
�/6
Sagnature oS i tor Regisk'ation Ntunber
� l�l�r�.�-_ � Y- �i6
Tyge of xe�is�afion Dare
While•Cvstomd:Cupy Yallow.C'ii�1s Capy PIDk-[asAtqofs CaBY