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CI'X'Y�T��PF�LI.,WAT�12 U'Z`ILI'FLES �
C[7S'�OMER SERVTCE fNSPEC'�T'k014 �
IZrsidentia! � . Commcrcial ❑ Tl`ntCC ID�057p04D �
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_ J Bt upon itmspection of ths private water distri�afion fapilities tocated at . �
_ � � � _ wkiickz i�c�nnected to the City of Cogpell FTatcr 5ystem,do hereby cez#ify �
: that,to ihe best of my knnwTedge;
In Nox- N/A �
�ompliance Compliance i�"
(I)� No direct connection between ths puhlic drinking water supplg and a patentiai �'J/ • �] p �
source of contaminaltoa exisis. Patentia� sovraes af aazrtUUmination are�isolated ' ' �
fzozn thc ublic water s stem b an aix �
� Y Y �ap or an appropriafe backfIow greyerrtion �
assemb3y in accordance with Commission regulations. ,
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{Z) No cross-connection bstweoa the gubIic drznkzng tivatar supp(y aud a private vrater � e] p
system��xists.��Ihera an ach�,il au gap is notttu�intaiued baNreen thc pubiic water �
snpply �nd private water sdpply, an approved reduced pressure xon� baek-t�ow � r
, prevention assambly is properly instalied and a seryice agreemerit nxisis for �
annual inspecfio�and testing by a aertifed baek#]4vt prevettkion device tester: �
(3) No conrtecdon exists w}ucfi would aI14w the rcturrt af tivater used far condensing .� [� �
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i coBTmg or lndusiria}proc�saes baek to tlie pnblic waeer supply, �
{4) Na pipe arpipe fitting vrhich eorttains mare than 8A%lead exisis i�privete watez �• p d �
distrihudan facilit�es instaIled on or aftex 7aIy I,1988. , �
{S) No solder or flux w�ich contains more thar�,4,2°/a lead axisFs in�-ivat� waier �[Q - p �
distn'bufion facilides instalred an or a#}er July'1,I988, � �
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Water servioe shall natbe prpvideti or restored to fhe private�vater disttihution fac�ides until the above eanditions are deteruciued io be �
itt cam�iliauca. �
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I certify that tbe£o]]o�,�izig materials�vi]]be used in tIia installation of the�rivace vratez dism'buti,on facilities I6c�ted at
a.vs r.� ;
aad that the inspecfior wiIl valiciflte iomp}lance dtLring the znspectiort process; ?
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Sorvice[ines Lead D Copper t7 PVC ' ❑ Qtli�r �
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Solder Lcad q Z.,ead Frea � Solvez�t Weld q Other �
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I recognize thar this document sha11 liacome a pezmanent recozr3 of tbe afo�emenfionad Publi��s�'ater Sysicm and that I azn Iegally �
responsz�b3�for the valid.ity of the in.formatzo�T have provided.
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C�s'�S /, :��G� � . �°
Type ofRegtstrarion � C'
Date
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Y recoguize that•this docurnent shall become s perniancnt record of.the aforementionad�qbli�Wafex 5ysiam�ad that I am tegal]y ''
respon�j5ie far tfie vulidity af the infocutation pravzded, ;t
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Ssgna[ure qS it�fipect Reg�slTatiouz�ber �
C✓'S'/�' �� (�- 2-G "�l�
Ty�te of xegis4xtion � Date .
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