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Itrsidentiai �'' . Commcrcial ❑ T1�IRCC SD�057604D �
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I �0�� c ��`i upon inspect3Qn o�tha pri��ate water distrihatiob fapilities located at . �
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���,�^l`-UB�i e G%L whiah.is cannected to the C;ty of Cappell Watcr 5ystem,do hereby certif}� � tl
: that,to the bast of my iwowTedge: '
. � �
Tn Non- T^UA ¢
Com It ce Car�Iiance ,�
(1) No djrect crnmectiun bet�v.esn tbe pttblic drznldng water supplg and a potantial � ' p q �
source of cantamiAation exisis. PotentixX souroes af cRzctumivation axe'iso]ated ' ' !�`
frozn th� ublic water s stem b an air �
1� Y Y �p or an appropriate backfIow prever�tion �
assembfy in eccordance with Commission regvlations. ,
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(2) i�To crnss-eonnectian belween fhe pu6Iic drinking water suppZy aud a privafe 3vatez � D q
system exists.�l�lhera an actu.il au gap is not maintained between the�ubIic waier �
supplp and piivate water snppty, an approved reduceci pressure-zon� baokf�ow ' �'.
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, prevention assambly is propariy instalied and a s�ryice agreement exisis for
annual ius ecfios�and tesfin b a certi#ied back#larv �
P $ y prevenk[on device tester: �
(3) No connecdan e�cisis whicfi would aI14w the rcturn af�vater used for condens�n�
b/ � ❑ C
s 000I'mg or industria}grocesses bac]c to the pnblia tivater suppiy, �`
{4) No pipa arpipe fitting vrhich corrtains mare than 8A%Iead exisis iA priv�te watez � �j p �
distri6ution facil�'kies ias2alled an or aftes TaIy I,I�88. , �
�S) No solder or flux w�ich coufains more thau 0.2% lead exisfs in privatc water � �[,] - p I'
distn'buf3on facilities insta]1ec1 an or a#}eY Juiy I,1988, �'
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Ys�ater sexvice shall notbe pravidad or restared to ihe private wates dist�ihufion fact7ides uncil the above eanditions aze deter�mned io be �
uz cam�iliattce.
I cczlify that tha follo��ing materiaIs tv�Il he used iu tha installati4n of tTte przvate wra#ez dism'burion facilities]dcated at
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,�� �� G v e/74,!�Pil� , _aad that the inspector will valtdEtte comp}lance d�tg the zrtspection process;
Sorvice lines Lead L7 Copper ❑ PVC ' Cf Qtli.er� �
5older S.ead q �.ead�'zea � Solvts�t Wel.d C,] Othar" ❑ `+:
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T recoo"e thet this doccunent shailliecome a paz�manenf recozY3 of thc aforementioned Publi�Water System and that I am tegally
responsx�b�for the vaIidity ofthe' rmatioz�T have prnvided.
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Sigttaturc LiGe � rl mbe�r 1Legisaaiiu.,•Number ;.'
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c�s�.� o���y--� . ,,
Type o�Regisirafion Date -—""" `
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Y xecoguize thabthis docurnent shal]become a perniancnt record of.the aforcinentioned Pnbli�Watcx Sys[am�ud that I am EegalIy �`
respon�jSIe for tfie v�lidity of the infonmation pravided, �,
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Sa aLure o�;It�pec[or �_
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Type ofxagish�ation Date -
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