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IFi��9m��nt�fi�� �, ��o�r,n��rs�a� � �[i'1 i13�'� ID k�4D5��3�D4�D
� ; '��m,�' �,��i i� , upon inspectio� ai tne p�:�r7�2 bV32�I distri'uu2�an facilities ]ocated �t
V ' k S .�Yn , dvhic� is cona�eci�d to the �i�� of�o�z�ell ��ia2er Syste�, do hereby ce�iify
that, to the bes4 of my knowl c�ge:
I,� �don- N/A
Co�}�lia�ce Co;a-�pliance
(1) IVo direct connection between the public drin'cing waYer supply and a po2ential � ❑ ❑
source of contamination exists. Poienrial sources of contamination are isolated
from the public water system by an air gap or an appropriate bac.{fla�N prevention
assembly in accordance with Commission regulations.
(2) No cross-connection beriveen the public drin,'cing water supply,and a privaie wacer � ❑ ❑
system exists. Where zn actual air gap is not maintained bet�een the�ublic water
supply and private water supply, an approved reduced pressure-zon� bac?::_�7ov;
prevenrion assembly is propezly installed and a ser�ice agreeme�Y exists for
annual inspection and testing by a certified backflow preve��ion dey�ic�xester.
(3) No connecrion exists whicb would allow the return o�f water used ior co��ens�g � � ❑
cooling or industrial processes bacic to the public dvater su�ply.
(4) No pipe or pipe fitting which contains more tLan �.0% lead exisis in private watei ,� ❑ ❑
distriburion facilities installed on or after July 1, 1988.
(5) No solder or rlux which contains more than 0.2% lead exists in �rivate vvacer � ❑ ❑
distriburion facilities installed on or after July 1, 1985.
V�later service shall not be provided or rzstored to fhe private water dismbuYia�i iacil�tizs un'til the above condir�ons arz deter_mined to be
in compliance.
I certify that the following materials will be used in the installa�ion of the priva±e tivaYer dis�-ibution�aciliries located at
7 U,� ��,(` �p r�h� ��. and that�e ius�ecior wi11 valiclate compliance dunng'the inspecYion process:
7�
Service lines Lead ❑ Copper ❑ �VC � Other �
Solder Lead � Lead Free � Solveni�Veld ❑ Other �
I recognize that this document shall become a permanent record o�`the aforementioned�'ublic V�later System and tha2 I am legally
respo �ble for the validity of the information I have provided.
� � � � �
Signa re of Licensed Pl mber kegistration 1�lumbei
.�Oa 5-�e_r S/�-1 // 6.
Type of Registration Date
I recognize that this document shall become a permanent record oi 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 Date
YJhite-Cus�omers Copy . Yellow-Ciry's Copy . Pink-laspeaors Copy