2016_0404 CI'�'Y()F COPPEL�WAT�It UTILITIES
CUSTOMER SERVICE fNSFECT3:Olti
Residentiai � Cnmmercial ❑ TNRCC ID#a57f�04D
I 6 � �l �c✓" /"'' upon inspection af the grn�ate water dis�ibution faniliriss 1c�ca[ed at
� r �✓� wllich is connacied to the City of Cappell Water System,do hereby ceztify
that,Eo ihe tsest of my knawledge:
� Non- Af1A
�ompIiancs �ampliance
(1) No direct comiectian between ths public drznking water suppIy and a potential �/� ' Q ❑
source of cantaminati.on exists. PoYentiaa sovrc�s of coumminaricsn are isolated ' '
from the public v�rater system by au air�ap or an appro�sriate backtIow preveniion
assembfy in accordance with Commission regesiations.
(2) No crass-connecEiou bEtween the puhL"€c drinking water suppIy aud a private wa#er ^ � D �
system exists,�EYtsere an actu�l aar gap is ua#matntained betw�eu the pubIic wat$r
suppIy and gr�vate water svpply, an approved reduced pressnrc-zqn� hackflow �
, prevenrion assombly is properly instalied and a service agreement exisis for
annnal is�speetio�and tesfing by a cerri�ed back#7ow prevenkion device tester:
(3) No cnnnectian exists which woufd aItow the retum af water used fnr cnndensing � p �
i cooTmg ar industrial proccsaes bartc to the pnblic tivater supply,
��) Na pipe orpipe�itting tivhich carrtaius mare than 8.,0°/a]ea�.exisfs in privxte watez �' p p
distributian facilities instaIled on ar afcez 7uly I,198$. ,
(5) No solder vr flux w�iich confains more tha�a, 0,2°/a lead exists in �rivatc water � � p � p
distn'bution facilitirs instzlSed on or af3er Juiy 1,I�SS,
, •
Water sesvice shall nat be provided or restored to fhe priva#e water disi�ihution fa�zliries until the al�ove eonditi.ons axe detemizned zo be
in conzpliattce.
I ccrtify thaE tbe fo�Ia��ing materiaIs will 6e used iu the installatian of the.psivate wa#er dism'bution faciIities Idcated at
��`+/t and that the inspectar will validate compllance d�.riug the znspection process;
Servsce lines Lead ❑ Copper � PVC ' ❑ Q��r �
5older �.ead ❑ Lead Frce �` Solveat We1d ❑ Othat ❑
k.`
I recggnize tbat this dacume sk�all liecome a pezmaneni reca�rd of tha aforemeatioucd 1'ublic Water System and that I azn Iegally
respons�b�for the vaIz ' f the infarmation I have provided.
_ /�
5i ature v ice rI Plumber R�is�ati�u•�TumbeF
Type of Re�trari�s�•..s .—' Date �`"y�� , �.
Z recognize that•this docurnent shaII hecome a perniaaent zecord af.#he aforemeutioned Publi�Water System aud tha#I am IegalIy
r�spon�5ie far the validity of the' ,a�ua4on pravisied,
/ �
Signature ox=in�peceor Registration Number
-�-.-� f y-y-��
1'ypo ofKegis�atian p�=�
Whi�e-Cvs[nmds Cupy YeNOw.CiSy`s Capy Pmk.IospeqoYs Cnpy