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CI'�X OT C�pP�LL�+'ATL�t U�I'I'LES �'�
C�TSTOMER SERVICE fN�SPEC'�'k01`: i
IZesidentiat [�" Commcrc't•al C7 'T'NRCC ID�65'1004D '�
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I � � ' upon itmspecfion of the grivate wa[er dislri6utiou faCiliEies locaced at . � �
&�y ,' � � wb.ickz is connected to the Ciry of Cappell Water 5ystenn,do hereby certify � �
that,to the best of my kstowTedge;
. � �
� � Tn Noz�- T^t1A �
Compiianca Corr�liance `
(t)� No direct cuunection betrv.cen Thc public dnnkiug water supply and a potantial �1f ' p ❑ r:
source of contantinatiou exisis. Patentia� sovraes af caztt�mination ure�isolated ' ' �
fzom the public water systeen 6y an aiz gap or an appropriate backfIow prevention �
assembfy in accordance wf th Couamission regtilations, ,
. , �
�2� No cross-connection between the gublic dr�nking watar suppZy arxd a privaic vrater ;(�` ['] p
system esists,�liThera an ac4uil airgap is uotmaintafued batween the public wa�et �
supply And pzivate �water snpgly, an approved reduced pressiue-r.Que baakt�oK� ' r;
, pra'vention assembly is proparly instalied and a service agreement cxisz� for �
annual ittspocTion.and#asting by a cerrifed bacic#l4rv prevention device tester: �
(3) 2do conrtecflan exisis whicfi wauld a11ow the rcturn af tivater used for condensing � � p
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; cooTmg or tttdustria}prflces�es back t�the pnblicwater'suppiy, �
(4) Na pipe orpipe�itting vvhich cor�tains mare than 8,0/a lead exisfs iA private water �- q [� �
distrihndan facili'iies insraIIed an or after.luIy I,1988. , �
• • .. �
, (S) No soldsr or flux vv#ich aoufains more thax�,Q,2°/, lead exists in privafe water � �L7 • p �
distn'bnkinn facil•lties fasta7led aa or a:fter Ju1y'1,I988, �_:
�. • �
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VsTater service shaIl natbe pr�vidad or restored to ffie private wat�r distribufioa fac�iaes until the above eonditions ara deteruzzned to be �
itt compliance. �
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I cer.tify that the follosving materials tvilI be used in tha insEallation of the pzivate vla#es dism'butzon facilities Idaated at �
aad that the inspectar tvil�vatidate comp�iance d�ning the inspection process;
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Sorvice lines Lead ❑ Copper ❑ PVC ' ❑ Qtlier � `
Solder Lead q �,ead Free � 5oiveuk Weld O Othar �r
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I rec�gnize that this document sha111iccome$pezmanenf recozti of the aforementioned Pnbli�Il�'ater System and that I am Iegally �
responsz�bl�for the validity oftho informatioz�T have provided. ;
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Sxgua nfLice Plnmber � It�isuaiiU..•Numb�r �
!�✓S�1' � .S'="2 c� /(� - �;
Type of RegrSlrarion Date '
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X recoguize thabthis doctuiient shaII become a ent recozd of.the aforementioned Pnblic Watex System a�nd tl�at I am Iegally k
r�spon�j5Ie for tfie validity afthe' on pravided. !:;
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Signature qS"iz�pector Registtatiou Number r
�.-S'/?S . ' S -�c' -/�O
Ty�e o xegush�tion Date _
WLi¢-Custom�rs Cupy YCIIO W•CII�3 CI1pY pj�����q�j
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