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J_ �� �.����(�iL��' �� �, � � _, uPon �nspection �o?i'_�z p�b��te �,v3,ei dist�`uutian iaciliti�s locatzd zi
�`�� �� � ^�r,���, �_, tivhicl3 is co�neci�ct to the CiT�j of�o��ell ��%z.tzr S�s4eri, do hereby ceicify
2hat,io thz best oi my lu�o��vledge:
�� �ion- �T/A
�Co�plia�c� C��p!ia�ce
(1) ido d�rect connectio� ��et+�✓een t-he public dri�i-�cing wa2er su�;�ly a�c1 a �o2en�al � ❑ ❑
source oi contz��zatie� exis�s, �oien�-�al sources oi coniarr�inaricn are isola�ed
irom ihe public water system by an air ga� or an app�opsiate bac'�i`lo��prevention
assenbly in accordance with Com�-nission regularions.
(2) I�10 cr�ss-coZnection bec�veen ihe pu�1_ic drinking v✓ater supply and a priva��e wa�er � ❑ ❑
system exists. �Vherz an actual air gap is not main�tasned ve�een tbe�u�1?c v�ater
supply and 7nvate c✓�ter supply, an approved reduced pressure-zo�� bacle�lou�
preventio� asse_nbly is properly uzstalled and a se��ic� agrez�znti ex�sis for
a�ual�spection znd 2esYing by a cer�izie�back�ow pgever�?io�de��ic�tes�er.
(3) 1�To c�n.nec4�on e:t15T5 yvhicn w�uld al]o�i t�e r�Yu�-n of wa2er use� fo� co��e�s�g � ❑ ❑
cooli.�g or indusT�ial��ocesses bacic to the public kuater su��ly.
(�) �o pipe or pipe fi�ting ��hich contains nore Than o.0% lead ex�s�s in private ��>>aYer �u � Q
dis�ibLtion facilities ins2a�led cn or after July 1, 1988.
(5) No solder or f1u� which con'rai.ns �ore than 0.2% ?ead exists ir� �rivare �✓a2er � ❑ ❑
distribu�ion facili2ies ins2alled on or after Ju1y 1, 1985.
v�later seniice shall�ot poe providel or�estor�,c Yo 1�ie priva2v w��e�dis'cnbuticr iacil�rzs�n�il �e a'oovz condit�cas �.�� cete�_-ni�ed to be
in com_pli2nce. "
I c�_�ify�a2�he io1lo�,ving anaterials will'oe used in the install_ai�c�n of t�e priva?z�,vate_r�is�ibu�o�r�c;lic�es located at
��� �ce.� �� ���� ��� and t'nat`�'r:e�s�ecto;v�il]va1;���corn�li�ce during the i�spec�ion p�acess:
Ser��ice l�es Lead � Copper ❑ rV� � Otiler �
So1�er Lead � I,ead�see ❑ Solt�e�i j✓Ueld ❑ t3rher �
I recoo ize 2ha4 this document shall become a ae_�anen4 record o��e a=for�7nentioned rublic 1�Uater 5ystem and Tha2 I an legally
respo� �ble for the validily o_�2��e information I ha-ve pro��ided.
' Q�,���� � � u � � �
Signa re of Licensed�l mber , kegistration�umber
,��0�5�� � / \S/ \ c.,
Type oi Registration Date
1 recognize that this document shall become a per.nanent record oi the aforementioned Public bVater System 2nd t�at I am legally
resoonsible for the validity oi t�'�e infomation prouided.
Si�nature of Inspector �egistration�iunber
Type of Registra4ion D�qz
V:�hi�e-Customcrs CopY � Y'ellow-Ciry's Copy, . Pink.Iaspenots Copy .