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I �j'�,CSj�';��('i���' ��� l, �� ( , u�on�zs��ction �7 t'�� pnv�tz �V3d�Z d15CI7�ll210Il i�C1I1�125 IOC2tZC] ai
�{5y �W�r� ih e, �- _ , dvhicls �s con?�ected to �'�e Cit�j o_F�'o��e11 z;�iatz; Syste_�, do h�reby cer_ify
that, io 2he bes: of ny lti�o��vledge:
�,-� �Ton- �i/A
Co�p�aance Co�plia�ce
(1) �o d�r�cY c�nnec�io� �eh,veen the publ�c drin'cing wa2er sup;�ly a�d a noten�ial �' ❑ ❑
source of centa���2tion exis�s. �oier�4�ia1 sources oi co�tarni��alicn are isola[ed
irom ihe public water systz�by an air g�p or an apr�Popriate bac'�f1o��✓prevention
assembly li�accordance with Corn�-�ssion regulations.
(2) 1�10 cross-connecnon ben;veen�tse pubi_ic drin,'cir_g vrater suaply and a p�va�.e wa�er ��� ❑ ❑
system exists. �Uhes� an actuaI air gap is not main�tained i�et�reen the�u�l?c v�atet
sup�ly and private w�.ter supnly, an approved red�c�(� �iI255Ur�-�p�� �acl;�lou�
pre��ent�on �ssembl_y is pro�erly u�s2alled and a sei��ic� a�ree�e�ati existis ior
a�ual�spection a.�d testiing by a ce�ried}aaci�flow preveniio�a de��icv xester.
(3) �o con_aec�ion e�cis2s vvhicn would allow th� retu�� of water use� io� co��ens�g � � ❑
cooling or indus�al��ocesses bacic to the public water su��1y.
��i� 1�0��pe or pipe fii�ing ��'�'11C�1 COF1T3ll75�OIe 2L�flIl o.�°�a 12aCi E�1Si5 ]Il,�iiYdie}i�/3Cei �� ] Q
dis�ibL�on iacilities installed�n or after Ju1y 1, 1985.
(5) No selder or r'1u� w1�.ich con'rau,s nore fhan 0.2% lead exis�s irz �rivur� dvater � 0 ❑
dis�ibu�ao�facilities installed on or after Ju1y 1, 1958,
V�Iater se�iicz s�.aL�ot ne arovided or��stcrd:l�o ihe priaat�w��e:cliscribu�iora_ac�l�iies �-�ti1"�e �'oovz co�dit-ions are cete;��ed to be
in corr:�_pl�ance.
I c�_�ify�hat the iclloyvino a aterials will'oe used in t�'�e installa�ios of�e privaie tivate:�is�ibu�io�7�cilities]oca�ed at
"l S_l �1,��h ���� �i�• and`�nat�'ne i�s�ectos v✓ill va1;�]a��ca�n�pl��ce dunn� °�ae:�zs�ec�ion process:
Serrice lines I.ead � Cop;�er ❑ �V� ❑ �2her �
Solder Lead � �,ead�ree ❑ 5olve:�t S✓Veld � t�Pher �
I recoo iz� 2hat i�is doeumeni shall become a pe_�nanent recorc'of t'az a�orymentioned rubl c �i�/aizr 5ys�tzm and Lha�3 an legally
respo� �ble for the validity o=f�1e information I have provided.
� �������� � � � �, �
Signature of Lic�nsed P1 mber kegis�-atiog Nur�ber
,��.a��-� $�36 /C6
Tyoe oi Registration Date
I recognize that this document snall become a�ernanent record oi the aforementioned Public �Nater System znd ihat I am legally
resoonsible ior the validily oi t�`�e infomation provided.
Signature o£Inspector �egist�ation Nnnber
Ty�e of�,egistra�ion Da2e
`h'hite-Cusiomers Copy , 1'ellow-Ciry's Coyy , Pinh-laspeno�s Copy