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CI"k'1'OT CppF�LT��AT��2 UTYI,ITIES �
CZ7S�'OMER SERVICE�SPEC�'�Ol':
Residential � Commcrcial ❑ TNItC��D#U57U040
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I � � ',� upon inspection of the private wa[er dutribufiod faoilities located at . � �
r � � whickz i�cnnnected to the City of Cappell Water System,do hereby cez#ify y
: that,to the best of my knowTedga; �
: � �
' Tn Non- NIA �
Comp�ce Corr�]iance �;
(1)� No direct cmmectton trehveen tbe public drinkiug water supply and a potential ��r ' ]] p `&
soume of cRntaminativa exisis. Pot�ntaa� sources af cozztqmination ure�iso]ated ' ' �
fram th��sublic tvater system by an air�ap or an appcopriate backEIow prevention
assembfy in accordance with Commission reguladans. , �
{2� No cYnss-connection betweea the pubTic drinking wazar supply aud a privaTe water � d O ;
systam-exists.�Wlrera an acWal au gap is nof maintaiaed beriveen the�ubIic watet
snpply und private water sdpgty, an approved redueed pressure zone bar3s�ow� � �;
, prei*entiori assembly is proparly instalied and a servic� agreement cxists for
annual inspecfion,snd testing by a oertif ed back#]arv prevenhion device tester: �
(3) I�10 connection exisis Wfucfi would allpw the rcturn of tivater used fnz conderasin�,
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; c�ol'mg os lttdustria}grocts�es back ta tha publia water supply, �
(4) Na pipa orpipe�itting which cozttuins mare[han 8,0°!a lead exisfs i�private watez �• C] d
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distri6ntian facili�les installed an or aftex 7ufy I,I988. �
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(S) No solder or flux w}aich confains more than 0.2% lead exis�s in privafe water � �p • p �
distn'bntion fac9l{ties instaTled oa oraf}er 7u1y F,I98$, ,
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�Yater service shall natbe pravidad or restored to fhe private water distrihution fac�iries until the above eanditiotis are detemunedio be �
itt coinpliance. � �
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I�mrtf��e f �,�ing materials�vil}6e used in the installation of the pnivate uratez dism'butzon facilities Idc�ted at �
6 C�� ��`�r'(„�� and that the inspector wiIl validnte comp3lapce d�nittg the znspectian process;
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Sservice lines Lead ❑ Copper t7 PVC ' ❑ Qtlier
Solder Lead L] 7.ead�'ree � Sol.vet�t Weld O Othet � e
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I recoo"e ehat this docvmenT shaTlliecvme a pez �,lit recozd af the aforemenfioned Publi�Water Systczn and that I am Iegall3� �
responsz-b for the validity ofthe i.nf'o ve pr�vided.
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Signa eafLise � Inmbar �tegistraiiu�.�Turob�F �
G�� s � r � , �'� �j� . i-;
Type oflZegisirafion Date —""' `
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I recoguize thabthis docurnent shalI become a pecmanent record of.the afore�mentioned�ub]i�Watex 5ystem a�nd that I am tegally `�
r�sponys3jble for tfie vatidity of the informalion pravided, �s
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Signa oS;Iz�pe tor Reg�sfs hozt Number � ;z
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'1'ypc of xegLsh�atiort Date ,"
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