2016_0604 �
, � ;
r
czxx or��r���,�,wAr��z u�zTr�s
CLTS'Z'ONIER�ERVICE fNSPEC�'k014 �
� r
Residential . Commcrcial C7 TIVItCC ID f�057f304D
�'r
I�.�p �o� ,�"_�� upon inspectinn o�the private water dis�ihution facilities locazed at . � `
'.�-� �i�io e f�-.� ` wbzckz is conuected to the City of Cappell Water 5ystem,do hereby certify �
: that,to the bast of my kuowTedga: �
. �
� Tn Non- NIA �
�ompliancs Car�liance f`h
(I)� No direct connection behYeen the pablqa drinldng water supply and a potantial � ' � �]
source of contamivarion exisis. Pat�ntia� souxces of coutnmivation are isolated ' ' ;;
frozn the ublic water s stem b an air '
� Y Y #�p or an appropriafe backflow prevention �
assembty in accnxdance with Com.mission regvlations. ,
' � �
(2� No crnss-connection behvean the public drinking�ater supply aud a privaie water � e] p �
systam e�ists,�1�hera an aaWal air gap is uof maintaiaed between the�ubIic watet �,"
supply and pzivate water sopply, an approved reduced pressnre-zoue haekf�ow� � i�
, preventioit �sscmbly is properly instalied and a seryice agreement nxisis for �
annual iuspecfia�and testing by a certified backflativ prevetttion device tester: ��
�
(3) No cannecrian e�cists w}ucfi would aIlow the retarn of water used£or cnndensing � [� �
��
s cool'mg or ludus�ia}proees�es baclt to tha pnblia�vater supply, f
�,
{4) No pipe arpipe firiing vsrhich contaizts more Chan 8,0%lead exisis iA priyate wates �• ❑ ['] �`
distrih�.dQn facih'i�es insTaIled an or aRex 7uIy I,I988. , �
� �
t5) No solder or fiux w3aich coAfains more than 4,2% lead exis�s ih private water �[,1 � � �
distn'bufion facilzties installed aa or a#3er 7uly'I,I?88, �
,. . EJ
�
Water sexvice shall natbe pravided or restared ta ihe private wat�r distrihufion facilides until the above eonditions ara deter�ned to be �
itt compliarice.
�
�
I ccr.tify that the folloa�ing materials�viIl 6e used iu thc installation of the private vra#ez dism'buti.on facilities Idaated at
�'�^ win.�e�,.e7�-� ,,,,_,_and that the inspector�vill validnte compkiauee d�ning khe znspecrion proeess;
Sorvice lirte5 Lead D Copper q P'tIC ' p Qtlier �:
5older �,ead L7 7.ead Frea � Solvet�t Weld p p��z p �.
a
I recognize that thiS docvmenT shaTl becoma a pez7naneuY recoxd of the aforemenfionad Publi�Water Systcm and Chat I am tegally �
responsz�b��for the validity of the inf'orrnation T have provided.
��� . �
SigttatureofLice� ae �egis�aixUu�N�umSef �'
�.✓SP�S � �'
Type ofR.egistrafion Date �� Y � �
. �:
Zrecoguize that�this doctunent shall become a pecinancnt record of.the aforementioned�'qbli�Watcx Sysiem and that I am tegalIy i'
r�spon3ij5ie fo tfia vali 'ty afthe' on pravided, � ,,
� � � � �
Signa[ure ox i1l�pec[or F
Re�isGcatio�Number
� -�-JSf�'S . � C- �//6 I
Ty�te of xegishxtion Date _ �
i�
Whi¢-Customdr COPY Yefla W.Ci4�s Capy Pirik-InsPeqat7 CnAY