2016_0908 �'3'�'��ctJF'��JFP,��ri;L �,?i��7',��11 U�'II.,I;I���
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I �� �,C1;('��i('i'���' ���� V ��� , �s�on �nspertion o�t'ne p�iva�e �V3iEI CI15IZ1tJ11C3DIl F�C1I1�1�5 70C2ted ai
`'1�� L. c� �rn� e,� � �� �..e. , tizihicl� ?s �onnect�d to �;�e CiT�j of f'o��el] ti�iater �yste�m, do hzreby cercify
2hat,io ihe besi oi my lc�-�o��vledge:
�-! l�ion- N/A
�Comp�iance �Co;�plia�ce
(1) �do direct connecYio� bei�✓een t-he public cirinl-�?cing watez su�;�ly a�c1 a �ot�.niial y� ❑ ❑
source af centa�-;�i�zation exis�s. �oter.t-ial sources oi co�taininaticn are isolated
iron ihe public water systzm by an a;r g�p or an ap�ropsiate llac:cflo��prevention
assembly in accordance with Corrli-nission regulations.
(2) r10 cross-coimection benveen�he publ_ic ciin,'cing v✓�ter su�pll�id a��ivaie wa�er � ❑ ❑
system exists. bUhere zn actuaI air gap is not?naintained be�een the��.�1?c v✓a�ter
suppl_y and �rivate v✓�ter sup�ly, an approved redraced przssiir�-zo�� bac1c�lou�
pre��enno� assenbly is pro�erly i��stalled and a se:��ice a�ree�netaY exisis for
ansual�nspection��d tes�g by a ce:�ifi�d bacl��ow preve�iiara de��icti tes7er.
(3) i�o con�ection e sisds w�icn �ould allov�� the reiw� of vvaier us�� io= co��e�s�g � ❑ ❑
cooli.ng or induscial��a�cesses bacl�to the public�atef su��iy.
(�') 1�10 pipe or�ipe fittin� �v�ich coatau�s �ore than o.0% leacl exis�s in p�vaie 7i��acer ,� C] �
dis�ibut_+on iacilities iz�scaalec� rn or after 7uly l, 1988.
(Sj i�lo selder or flux w�aich co��ains nore fhan 0.2% lead exists ��z r�-ivar� �v�cer � 0 ❑
distribu�on facili�ies ins2alled on or�fter July 1, 1988.
V+Iater se�iice s�.aIl no�ve?�rovided or��storrd Yo 7�e�rivate�w�te�clss'r�buEian iaczli�ies t�n2i1"�he �'oovz co�dic�ons are cete�_-miaed to be
in con_pliance.
I cd��ify�hat the£ollodvino n�.ierials will'oe used in�'�e i�.stalla�io�oFthe priv��re�,Uate��.is�ibu�on r�ci_1_icies located a2
`'1,�� �p�,�, � �, � � ���^' and'�'naY°�'rz i_as�ectoi v✓il�vai_iclat�car,n���ce dunno��b.�i-�s�ecrion prccess:
Serrice lines y ead � Capper ❑ �V� � C�ther �
Sol�er Lead � L,ead�ree � Sol��e���Neld ❑ flPher �
I recoo ize that this docLmeni sha11 become a pe_�n�nent recorc!�f t'az afor�mentior�ed�"ublic��Vatzr 5ystem and that I an legally
�es�o� ble fcr the validity ci tl�e ir�formation I have provided.
�
� ���� � u � � �
Signature of Licensed Pl mber , kegis�ation�lumbei
����=�� � 1 � / � C
Type oi�egisttation Date
I recognize that this document shall become a pernanen4 record oi the aforemeationed Public�Nater System znd that I am legally
res;oonsible ior ihe validity oi the inior-�ztion provided.
Si�nature oFZnspector �egistration i�iunber
!ype of�.egistra�ion . Datz
�Nhiie-Customels Copy 1'ellow-Ciry's Cepy . . Pink-Iaspecto�s Copy