2016_0714 CI�'Y OI���PF�X,L WA.T��2 U'.I`XLITIES
CtJS'�i)MEF��ERVTCE fI�SPEC',I'�OI4
Residentiai [�3" . Commcreial ❑ TNk�C ZD f1�57U04D
I �V� ` i `' / upolz izispection of ths griti��te wa[er distxi6ufiob faCilities located at . �
, ' � _ wbickz is cnnneci�ed to the City of CoppeII Water 5ystem,do hereby ceztify �
: that,to ihe best of my knowTedge:
� ' Yn Noz�- NIA
�omplianca Carr�Iiance
(I)• No darect connecrian betv�een tbe putylic drinking water suppI� and a potential �/ ' t] �]
source of cvnta�rvnativn exisis, Pt�t�ntaa�i sovxces af aantAmination are�iso]ated ' '
fram th��Sublic water system by an air�ap or an appropriaEe backfIow pxeverr�iqn
assembfy zn accordance with Com�mssion regnlatians. .
(z) No�oss-connectivn behveau the gu6Iic driuking water suppZy aud a private water �' [� p
systcm��xists.��hera an ac4uil au gap is nof maintained baturecu the�u�Iic watsr
snpply and pzivate water sdpply, an appmyed raduced pressure zon� bar�ow �
. pxeveution assambly is propariy iustalied and a ssrvic� agreement cxists fdr
annual inspectio�and testing by a certified l�ack#]azv prevettti�on deviae tester:
(3) No connecflan ex.isis Which would aI]ow khe retu�Tt af tivater used£az condens�n� � p �
F cool'mg or indusiraa}grocesaes back ta tha publia water suppiy,
{4) Na pipe arpipe�itting vsrhich eor�taizis mare tban 8,0°�0 lead.exisfs in private watez �• �] p
distrihudon faciliacs installed an rn after.7ufy I,1988. ,
tS) No solder or flux �v3�ich copfains more than. 4.2% lead e�s�s in�rivate water � �p • p
distn'bndon facilzties instaTled aa or a#}er 7uly 1,1�88,
,. •
�Yater service shail ttatbe pravidad or restored to fhe private vvatez�distrihufion fact7�ides until the above eanditious are deteizrzined to be
itz com,pliance.
I,certlfy that t17e fol]oW�n materiaIs tvill 6e used iu th�installatiop of the�rivace wa#ez dism'but�an facilities I6cated at
�� `ties'�u� aad that the inspectar WiI�validxte compklance dttring the i.nspection process:
��
� , .
Servtce Iines Lead � Copper ❑ PVC ' ❑ Rtlicr�
Solder I.ead CJ X.ead�'rea � Solvent We2d CI OtIiaz" ❑
a
T rec�gnize that this docvmant shaTl liecome a nnent recozX3 of thc a#'orementioned Publi��Yater Systcm and that Z am tegalJy
responsz�7g for the validity of the info ' n T have provided.
` � .
Sigttatuze n�'Lise � mber �tegisaaiiu,�•NumbeF
Type of R gistrarionf Date �_/���� .'"'"
Z recoguize that this docturient shalI become a pemianent record of.the afore�mentioncd Pnbli�Wa#ex System and that I am IegalI�r
r�spon�jble for thc validity of th.e info pravzded.
� � �/7
Signature Iz�pector Re�isGatiou Number
� �s �'f �� �� y��� .
Typ� of�ce�ish�ation Date .
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