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2016_0518 �3�''1��',��UPP,';,�r�,L, -�,��,��7'�,��r�ir7LI;11;"� �'IJ�"I�C�l✓I�'��i��'�T<<�':�: 'Ir.i�Pi;!�"T?�i� LR;P��nQ�� , �'�onm�prs�z7� � 11 I��L'1�k;��D�1�0 ��- r� III j ��I ��,� �� I' 'V [�U� , li�U071 Lt1S�7�C't10;] 4D�r i'_�12. j��b''�cC� �V32�I GI15[T1'l�lli3CZ] i�1C111i1�S �OC2izCj 2t �, „ ��l'� . �j�.,Q„�! � _ , tivhicl� �s �o_�eci�d to 1ze Cit�j o��'o��e�l �i�%atee �yste�, clo hereby cerify thai,io the oesi oi my lti�o��ledge: �,� �1on- �i/A Comp1_ianc� Co�plia�ce (1) 1d� d�rec4 connection bet��veen the pubi_ic drir�c�g wa�eg su�;�1_y a�d a �oien�al � � ❑ source cf conizni��ation e�is"s. 2oient-ial sources oi co�?ta��unaiion are isolated fron tbe public water system by an zir be� or an appro��ate bac�flo��prevention asse�bly L-�accorda;�ce wiih Co�-nission regulations. (2) I�10 c_oss-coiu�ecrion bet�veen �he public -1�rin,'cing vda2ez si�ply and a p�iva��e warer � ❑ ❑ system exisis. bUhere an actual air bap is not mz;�taL-�ec�bee�.veen The�sublic v✓atez supaly �.�d �rivaie �✓ater supply, an. approved reduce� przssurP-zon� bac?u!ou� pfev�n�±o� assenbly i; �roperly installed and a seriice agree�e�aY ex�sis io� z�ua1+�spection�ad�esti?�g by a ces-rined bac��iobv preve�:ia�a�evice tester. -'(3) No coLnection e„ists �vh�c'� w�uid allow t�e �eCU�.il Ol`�1Vr1ieP ilS2C� io_ co�c�ens�g � � ❑ cooi_ing os inc�us�ial pr+�cesses bzcic to fhe public water su;,,�1_y. (�) �o pipe o:�ipe fit`ting ,vsich contau�s no_e 2ha� 0.0% iead exists i�;��vaie ��a�er � � ❑ disfinbuTen facilities ir.s2alled on or aiter July 1, 19oS. (5) �10 solder or f1u� u�hich cantains morz than 0.2°/o Ies7Cl 2X1Si5 in �rivare �dater � � ❑ dis�bution facilities �stalled on.or after July 1_, 1900. . Y1T2'ieI SeP/1CZ S�.c.��Il02'De�IOVIQ��G=:�S�OP�;�$0 �2'pr1Y�i�4d�i�i C�]S�1vU�1G.�'i i3C1��uZ5 L211'`�e �'OOV�CO�.�1nOIlS 2.I� CZtEi_�i11Z1�C1 i0 be �compliLnce. �ce.�ify��t t'ae`ollodvir�-7aterials v�iL'oe uszd� the insta1]a�o�of t�e pri�i�ie tivaYe=dis�ba��on raciliTaes loca2z� a� � � �„---. �'�jlCjt 1�,�,�(_� - _. and�aY�e i�es�ectcr v�ill va1_;c1at�com�li�ce during `�z�.s;,ection�rocess: Ser�rice l�-�es Y,ead � Coppe� � �V� ❑ �iher � Solder Lead � �ead F_ee ❑ 5ol��e:�i j�Veld � O�er �, I I2CO�I11Z2 �hat��iis documeni s�a11 becone a per_nanent recosc] oi thz a_for�mer��ioned Fublic��Uaiz:Sys�en�nd�haT I an legaliy respon �ble for khe validiTy o�`t;�e Lnfortration I have provided. � �.��I �� I � �, � Signature of Licensed P•1 mber '��eeistratio�l�urnber .��5-� ��. � � � 1 ype of Registation 17ate 1 recognize that this document shall become a permanent record oi the aiorementioned�:blic�Nater Systen and`�tai I am legzlly responsible for�he validi��o�the iniornation provided. Signature of Inspector Registration 1�ium_ber Tyi z oz Regis«aYio� Date � �Nhite-Customers Cooy Yc;dow-Ciry's Copy Pia:,-lasyeaa�s Copy.