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2016_0609
�'3'T,1 ��i� �C�Jt��;,�ri;i },;/,�T,J��7�'ir1LI�?��:� �'II�'�_1'!L�1/�'?;'C1��>Jl�:�'il? �1 iJP;�;�. i 3 �'1' ��1� i?�.>>r]P��fia�9 ��' ��onn�e.r���➢ � 'Ti i�'C�?,i ��'D����D�;�D ��� ��, �' � 9 � 1i�C�'�j�11 ����' ��' l'� �I II� , u�cn ?�s�ect;on �f i'�2. p�iti�acz ;v3tE: dist-i`uution i�ci1_i�es ]ecated ai � --�=�� � � .a�."e,a` � �-�—"C 4'—�4V�73Ci7 �S �6�nPr1��C] t0 ��7' C1T�f 0_F�fl����l Zi�/2.C2i S f5ke�, C�0 '12I�b f Cei(Ify ��at, io thz bes�`oi my la�o��lzdge: � �L� �ion- N/A � � � �Cornp�ianee �Ca��lia,ce (1) �To d��ec'r consec�io_?. ',�eh,vee� t-he pubiic d�.���'cing watez° sn,�ply anr�1 a po��nizal r< � ❑ scu: e a_` conta���atio� exis�s. �oter�t-aal sources oi co�tar.rinaric. are isolated i:oz ,. ihe pul^l.ir. �z�aier system by an ai� ga� or an a���or�-iat�LackI�IO�N�2�VP_n_h0II asse���b1y ia�accordance��vith Corn�-nission regulations. � (2) l�lo r�oss-coznec�io�ber�veen the publ_ic �rink�rig waTer su�ply�ud a��ivaie wa�er ��� p ❑ s;stern exists. b�e-z an actuaI a��-oa?� is�ot 7nainrained i�e�een rhe�u�1�c~watei sup�oi_y ancl pri��zte w�ter sup�ly, a.n a�proved reducecl pressur�-z��e bac?,_�ov; p�e��e�t�o� asse�bl_y is pro�erly i��stalled and a se�iic: agrze-7e�ti exisis for ��ual is�ection and'cesci��by a cr�ined'aac�r'�ow pze-ve�=i��devicv Y�s'rer. (3) t�io conneci�en e;ists whic� �%��nld zllov�i tLz retu�� of vvai�r used�o: c��±�e�s�g � ❑ ❑ cool_i�� o:�,�dus�al�_ocess�,s bac1�to the publicµiztes su�ply. ��r� 1�0�J�pe OF�1�J2 ?1irtLP_�ikZCh COIIir7L�S n0=e i�2Il o.�°�a lead �;Z�5�5 17�i,I7V3i� �i�/r7[eI �� [] 0 0 disLi�L�`�on Tacili�ies i.�s'��1_�e��,n or a_f�er Ju1_y 1, 19oS, �(5) �io selder o: ilu�_ u�H�ch co,�'raz�s �or� Yhan 0.2% iead e�ists � �TivarP dvzcei `� f� 0 dis�b�tic�lacili�ies i�stall�d o�or a��e_r Tu1_y l, 1900. ,i`l��PL S�PI�C� �='.�'_1 �0'i i�e i0?OVld�;i Oi��StO_yL� �O �17e TJi7Yu��,tid3iel C�1527tJ11C1dP1 idC��iL1Z5 L71C�1 '`�2 �'OOV� CO�C�li7GIl5 2?� CeiZa_!�eG i0 b� »COI�!L1�21C;', ' i cv�fy u'�at�d�e#oilo�vvino�a2�.rials w��l oe ns�d in��e installai�o�ofh'�e p�v��te wate_dissibut-ion i�c;s�es loca?ed at � ��� °�'�:� �. ��� � an��nat u�z i�.s�ec2or v�;l'!val;�,��co��3i�ce d�g �e i�s�ecricn process: Se�iice l��es Lead �] Cop;�e� � ?V� � �O�her � Solder � Lead � Lead r-ee �7 0 5olvea���✓Veld ❑ O�er ,� , � 1 reco�il,e the�'t�is do�_urien�s'�all oecorn� a pe_�ianen�t record ai r�e�.iorv�-nen�tione��ublic�I�Izier�ys�tem and ihat�arn legally .�spo�sibl_e fo_ r;ze uali_d;ty cf t_�e i,zrornatios Z'_nave pro�i�ded. i � � i � � I( p l i � 'I � \`�/���' IC�.a���':,,��/ �`i ;I u II, C� Sijnature oFLic.ensed?]�-noer �cegistration Nurnber �/1�Ln_;•-�'� � � �.. lype oi Reg�s�aiion Date 1 recognize thaT ihis documznt shall become��ernanent record oi the aiorementioned Fublic�Nater System znd that I am 1_egally resnonsible ior u`�e validi"ry o-the iniom_a�ion provided. Si�natu_e of Tnspector 2�Zegistration t�iunber TYpe of�eoistra�icn Da2e `h'hi�e-Cusiome�s Copy _ 1'ellow-Ciry'�Coqy � , Pin_�:-laspenols Capy