2016_0815 �3T�1 �F���FP;,���;�,�;y��T����71ir1LI�;'���
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lA��ir��enra�7 �' �:�omr.n�e��c�a� � Z'1 I�3'r�IID k�'{���O���D
—r�-1��� ��II Pi��' �l' ! l�C-'� ' ; � `%
I C� ��� � l� � , .��on ns�tict�on o�t'_ne p:iti�a2� iader dist_ibu2ion f�c;liii�s located zt
. -1�3 �l..r�ti Q��1P C� , tiuhicll is con�eci�cl to �I�e �Cit�J of�o�aell �i�iatz� �yste_�, do hereby ce�cify
Zhat, io �he besd oi my lu-�o�:vledge:
�-� �ion- �i/A
�Comp�iance �Ca��liance
(1) �To direct c�nnectio� �et-1,veen the public drin?cing waTez su�;�ly �P1C� a poceniial � ❑ ❑
source ci contanination exiss. �'oter�-ial sources oi coataminaticn are isolated
iron ihe public water system by an 2u g�p or an app�or��ate vac:tilo�w prevention
assembly in accordance with Corrli-n�ssion regulations.
(Z) I�o cross-connection ber�;veen�he pubi_ic cLin,'cing water su�ply�nd a��va�.e warer � ❑ ❑
systern exists. WUhere an actuaI zir aap is not mainiasned veEween t3�e�u'clic water
supply and �nvate w�ter sup�ly, aa� a�prc�ved rzdr�ced przs.�_�re-zone bac';_�low
preventio� �ssembl_� is �ro�erly i�-�s2alled and a se�iice agrez�e�aY ex?sis Lor
a�ual ins�ection�nd 2es�g by a ce�tified bac��low pPeven:ion de��ice Yester.
(3) i�o con_nection e�is2s w�i�'cn wauld allo�i t�e retw� �f tiva��r usz� �or co��ens�g � ❑ ❑
cooling or indus�ial��ocesses back to tne public water sun�ly.
(�') 1do pipe or pipe fiiting ���ich contau�s _nore tha� 0.0% leacl exisis ia p�vate ���acer ,�'� �] 0
dis�ibL�±on iacilities i.ns�alled on or after July 1, 1985.
(�) �lo selder or flux �vvhich co�tains �ore ¢1�an 0.2% lead zxis�s si �rivar� dvzcer � � ❑
distribution facilities izstalled on.or af�er Ju1y 1, 19SS.
v+later sen�ice sh�Tl�o�i�e provided or restosdc Yo t1 e privat�,w��e�dis'mbucia�racil��izs LnTil �e a'o�ove co�dic�cns are dete�_–mined to be
i comrliance.
I cd��ify�ha2�he iollodving n�terials vdill'oz uszd in the i�stalla�ion of ti-ie priv�tz tivate=�.is�ibu�on r�cilities loca2ed at
�6� ��'n/�h ��'1C, C�}- and t'rsat`�ne ir,s�eci�;v✓i1�vai_;ciate corr�li2�ce�unno �e:ir.sz�ec'rion process:
�
Seniice lines I,ead � Cop�er ❑ r V� � �t�er �
Solder Lead � I,ead�ree � 5olvea���✓Veld ❑ �ther �$
I rzcognize �hai this documeni s'�all oecome a pe_�manent reco�cl �f t'�z a=fo��i�aentioned�ublic�Uaies System and 2.�at I a�legal_ly
:espo� �ble for the validity of tl�e informaTion I hzve provided.
�"� �,�.:y���G� � u –'I,
� I
Signa re of I,icensed Pl 7nber kegistration N�±mber.
�%�a�:�-� g! �s/��_
Type oi Registation Date
1 recognize that ihis document snall become a permanenf record ai the aforementioned Public Water System and that I am legally
responsible for ihe validity oi the iniomation provided.
Si�nah!re of Znspector Registra2ion 1�Iunber
Type of�'.egistra�ion D�q�
�Nhi�e-Cusiomcrs CoDY � Yellow-Ciry's Copy _ Pink-Inspeao�s Copy .