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1F�n���c]�nfia�9 � �L�o�r�n�e.r�c��� � Z'1 i�'r'� IID"!fD570��1:D
� �`a ' �I . .
I �� \,G�;����I ���' ��'��L, �� � _ , ����on�nspert,o� af tne p�vaTe �,va2ez dis�i`uu2ao� a,�cilities located a�
u�� �O�C�r'1 �t/�.� �'. , whicl� is cc_�nect�d to che �Ciri� o_f�o��ell ti;�iate;SysteY-,, clo hereby cercify
2�'�at,io 2nz best o�my lti�o1:vledge:
�� �Ton- N/A
Co�np�iance �Ca�plia�ce
(7) �do d±rect connection behveen the public drin�:ing wa4ez su�;�ly a�d a �otent�a] �� ❑ ❑
source ai ccnta�-�unation exis�s. �oier�4-ial sources oi contami��a2icn are isolated
iram the pubiic water systzm by an air ga� or an ap�pop�iate bac:�flo��v pqevention
assembly in accordance with Corcli-nissioZ regulations.
(2) 1�10 cposs-coznection benveen the public cLrixlicing water suaply 3rid a��iva��e wa'r_er ��� ❑ ❑
system exists. �Uheie zn �ctuaI ai�gap is not maini.airted�ei+�een�he�u.b1?c vrater
supply and �rivate water supply, an appzoved reduced �resstie-z��e bacic�low
preventio� �ssernbly is properly i�zstalled and a ser�ice agrez�e�aY exisis for
a�r.ual�spection and tesYi�g by a ce�ifi�d back�ow preve�tion dez�ic�xuster.
(3) No con.nection exists whic� would zllowi Y�z reYu�� t�i�vater us2d _oP co��ens�g � � ❑
cooling or indusuial psocesses bacic to the public water sup�:ly.
(�) 1 do pipe or pipe iitiing���ich co�tains nore than 8.0% leacl ex�s�s in;�xivate��va'rei �u �] 0
dis�ibLt�on facilities ins��lled on or after July 1, 1988.
(5) I�10 selder or flux which con'rains nore than 0.2% lead exis�s �z ��rivar� dvacer �� � ❑
distributio�facilities installed on or after 3u1_y 1, 19SS,
b+la�er se��ice s�all�ot oe provided or_estos�e� Yo ihe pnva2�v✓ate:dasmbu�ticr=aciliiizs Lnril the a'oovz co�di�o�s are deie�_-ru�ed to be
in cor�_�,liance.
7 ce��ify th�2 tne follodving n�terials wiil'oz� zd in u'�e ir�.st:all��on os ti�e prv�+.e tiUaYe��.isaibu�o�r'�cili�es loc�2ed at
�'�"l l l�b��''"� V�-� ��� an�.�ha�`se ir.s�ector��i1�vai_idat�cflrn�liaz�ce dun�B'�e i�-�s�ecrion process:
Ser�iice lines I,ead � Cop;�er Ci r V� ❑ Other �
So1�er Lead � �,ead��ee C� Solve��j✓Ueld ❑ Other �
I recoo izz Ghat i�is documeni shall oecorr_e a;�erznanenT recoscl �i the arore�en�:ioned�'ublic�V�later System�nd�ha?I an legally
_espo� �ble for the validity o_F t��e info:naiion I have provided.
������ � II � �i�, �
Signature of Licensed P1 mber kegis�ation�u�ribei .
d//����� �� 3d� � ��
Type oi Regisration Date
1 recognize that this document shall oecome a permanent record of the aforementioned Public Water System 2nd t�at I am legally
responsible ior�he validily oi t��e infor�aiion provided.
Si�nature of Inspector Registration 1�iumber
Type of?tegistratic� DaTz
`�'hiie-Customers Copy }'ellow-Ciry's Copy. . Pink-laspenors Copy .