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CiTS'�015�ER SERVICE�N�SPEC�'kOiti �
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Residential Commcrc[al ❑ TN12CC ZD��5'1U04D =
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- - upott mspecfion o�the pri��ate water dutzik+Utinn faGiliAEs located at . i ��
� wbzck�is connected to ttie City of Cappell Water 5ystem,do herebp ceztity �
that,to the bcst of my owTedge:
�
. � �
rn Non- NlA �
� Com liancs Compliance �
(1)� No direct cvnrrection behv.een tbs public drinldug water supplg and a potantial � ' p q '�
sonxce of cvntaminatipn exisis. Potential souroes af aomt�mination are�iso]ated ' ' !'
fram tho ublic water s ste€n b an aiz �
1� Y Y �.p or an appropriate backfIow preverrtion C
assemb3y in accordance with Commission reg�lations. .
(Z) No cross-connection b�tween the pubI�c drinking water supply a¢d a privafe wate� �' d p
systam�exists,�S�Ihera an ac4uil air gap is notmaintafned betweea the pubIic waieX `
snpply And grivate water sdpgly, an approved reduced pressurc zon� baektlow � �`
, pxei*entioti assembly is properly instalied and a service agre�nerit nxisxs for �
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annuai iuspecfion.and testing by a ce�ed backflntv prevenkion device tester: �
(3) No canrtecdon exisis w}rich would aIIPw the rcturn of tvater used£or cnndens�Ln�, (� [� �]
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; cnaTmg or lttdusiria}procesaes back ta tha publia�vatsr suppiy, �
(4) Na pipa arpipe fitting vvhich corrtains mare[han 8,0%]ead exisfs i�private watez �• q [� �
distri6udan facih�tfes insralled on nr after•7uIy I,1988. ,
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(S) No solder or flux vl3aich aonfains more that�, 0,2°/a lead exisFs ih privafe water �[Q � ❑ �
distn'bntion facilities inst�7led an or�#}er 7u�y I,I988. � �
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Water service sha11 ttatbs pravided or restored to fhe private water disttihutinn facilidas until the above eond3tions are datezaiined io be ;
m com�iliarice.
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I cer.tify fhaE tbe£olla ' g materiaIs�vil]6e used in th�installation of the privace ara#ez dism'but�ion facilities Idcated at
� �/+���C aad that the inspector tvill validate comp3lance deucng the znspectivn process;
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Sorvice lines Lead ❑ Copper p pVC • Cf ptlier �'4
Sold�r S.ead q 7.eac3 Frea � Solveut W�d O Othez� �
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I recognize thae this document shaTl bccome a permanent reco of the aforementionad Public Water Systcm and that I am Iegally
responsz�b��for the vaIidity of the informatiam T ` i ed. �
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Sxg�atura of iee tIP cr �tegisaaiAu.�Numbef �
4/ Sf��.S' - ' , C6 '/G � �
Type ofRegisirafion Date —'"`
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Crecognize thaDthis doctuneni shall becoma a permanent racord of.the aforementioned pqbli�Wafex 5ystem a�nd tLha#I am Iegall� i�
respon�jSle for e vaGdity af the infoanation provi ,M
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Signa[ure pS;�n�pector Regish`atio ber �
T o of rtagish�at� �� . , ��� �l� r;
Y� on Date ����
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