2016_0604 9
@
' ^ , ... � , ., , , _ '�
czxx ar��rg�r.�,war��u��z�rt�s
C;JS'Z'QNIER SF�RVICE�INSPEC�'k014 i
� l
Residential Commcre't•al ❑ TNR�C ID f�U57004Q ;
' �
I /.� 4.0 � �
- - upon inspecfiQn of th�grivate water distxi6utinn faCili[ies located at . i E
6 Z wkuckz i�connected to the City of Goppall Water 5ystem,do hereby ceztity
: that,to the bast of my 1wowTedga: �
: � �
Tn Non- T�t1A �
(1) No dizect connection behucen the public drinking water supply and a potentiaI ��m�anc� •���t�Ce '!r'
source of contam'tnation exists. Potentisa souraes af acrotnmination are iso]ated � ' p
L
from th�pubLic Water sysfe€n 6y an air�a.p or an appropriate backfIow preverrtion �'
assembty in accordance cvith Commission reg�ladons, , ��
{2) ?Qo cross-connection behveen the pub3ic drinking water suppiy aud a priva[e water �
system esists.�S�lhera an ac4�1 air gap is not maintained betweea the�ubIic water � � �
snpp]y and private water sopplY, an apprnved reduced pressare-rsane b�ckt�ow ' if
, prevehtion assambly i� properly instalied and a service agreement cxista for t
annual inspocfio�and#esting by a certi#ied backflntiv prevenkion device tester: �
�
(3) ATo cnnnecdon exists which wottld aIl4w the rctunt of water used for cnndensin� �/ Q � �
f cooling or indusiiia}procesaes baek to tha publie water supply, �,
;;
(4) No piye orpipe fitting vrhich oorMaiz�s mare tfian&,0°/a lead exisfs iA private watez �• p � �
distri6utian facilities installed an or after.7uIy I,I988, �
� f;
{S) No solder or fTuX vr3aich ooptzins more than,0,2% lead exisEs in�srivat� water �II � � r
distn'bution facilities instal]ed an or after July I,1988, �;
Y. , �j
C
T�Tater service sha11 naibe pravidad or restored to the private wat�r disttihutina facilitias uncil the above eonditions are deterrnined io be
in compliztzca.
�
I c�rtify that tbe fo]lo�-ing materials EviII 6e used iu the installation of the pziva[a wa#ez dism'bu�ion facilities Ide�ted at �
0 aud that the inspector�vill valtdute comp3lance dming the inspectivn pcoeess:
� ;
Servica li�es Lead 17 Coppec C7 PVC ' ❑ �tlier
5older Lead L7 , J.ead Prea � � 'Solveht Weld [J Othex� �
a
I recognize thaf this docvment shall becoma a pezmanenf rccozt3 of the aforementioned Pnblic Water System and that I atn Iegally �`
responsz�b��for e vaIidity ofthe informatzoz�T have provided.
�
� � i;
Signaturc ofLice � rI er �tegisvaiA�..•Numb�f �
,
� �;:
Type ofRegisfi'afion � Date � � - G�
• ;`;
Y recoguize that�this doctunent shall t,ecome e penttaneni recozd of.the a£orementioned.pqblic�VJatex Sys[am�ud tha#I am legally �
respon�53e for tfi ya(idity afthe infotutation pravide i,
�f/> E
Signa[ure qX;�t�pec[or RegistraUon Number � �'
�✓ S .r . / 4 j�l :.
Ty�te oFxeg�s4xt:on � Date ,�" �
ir
i�
Whi¢-Custamcr�CUPY Yc{lovt-Cit�s Capy
Piri1c•ImPCdofS GAY
�.,— .. -. .-- ___ _—.._____ — d