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� �U�T�C�r✓I�'���r�✓n���,�i.1�PL�LT3��l� .
]F������r��nfi�a9 � �v�n��rsaa� � �'tl�!CS ID�'�D57��O�1�D
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I b" ��;���i�' �P� �i��� , upon LZS�2Ct1O:l OT Lrl�P�Vatz sv32er dist�bution iacili�i�s ]ocated a�
�Z. S oc ���, .�� � , �vhicll is CGP�T PCi�d to he �Cirij of�op�ell ���Iater Systen, do h�reby cer�ify
L�at,io the best oi ny lti�o��ledge: -
Ia Tion- N/�
Compliancz Co�pliance
(1) �o d�_ecY co�sectioZ '�etween the publ_ic dril-i:ting water supnly and a q�o2en�ial � ❑ ❑
source ci con�a��zatio� exists. �?o�ential sources oi contamiaation are isolated
iron ihe pubi_ic water syste�-!by an air gap or an appTopriate bacl:fi_o��prevention
assenbly in zccordance wit�'�Com.��ission regu.larions.
(2) l�o cross-connectioa be�veen the publ_ic dr.in.'cing water sna�l�and a pri.vate water . � ❑ ❑
systen exis�s. �Vhere zn actnaI air bap is not maintained be�een the q�ubtic v�at�r
suppi_y and Nnvate w�ter supnly, an approved reduced presstiTz-zo�e bac?c�lou� .
preventio� assembly is properly iastalle�. and a serfice agrez�znY e,�sts for
. a�uai ins�ection and tesiig by a certifi�d bac��otia preveatio�device tes2er.
(3) No cor.r.ection exis2s w1-�,'ch would alloui tb.e retuL-n of wat�r used �or ca��cle�si�g � ❑ ❑
cocl_�g or indus�al p_ocesses bacic to the public water su��ly.
(�) T�o pi�e or pipe Tiiting ���i�'ch contai.ns no:e ihan S.0% lead e;�sis ia pi�vaie �iaier �,c ❑ ❑
dis�iUntion iac�liries i�.staLled on or after 3uly 1, 1988.
(5) I�]o selder o: ilux w�ich contai.ns r�ore than 0.2% lead exisis in privarP tivater � ❑ ❑
distn'b�tion Facilities ins;alled on or aF�er Juiy 1, 19So.
VjTzter sen�ice shaL1 �o�tie provided or=estor�,d To the privaTz waP.ei disi:ibufian faciLiizs �ntil"�e aoove co�di�o�s zre dete���iaed to be
i�con_pliance. �
1 c�_�i.�that t'�e ioilorving naterials will be used in t�'�e installa�io�of ihe pnvaYe water dis�ibu�ion fac'L1it�es located at
�����,�,� �� „.,,.�_ � Z_� and�at t'az ins�ector u�i13 vai;�t�co�pliance duri�g ihe i�-�specrion process:
Ser�iice I��es I,ead � Cop�er ❑ PV� ❑ Other �
Solder Lead '� il,ead:�ree ❑ So1��enijNeld '❑ Other �
I_-ecog-n.izz that this docnment shall become a pzTnanent record oi t�e aiorementioned k'ublic Water System and ihat I an legally
:espo� �ble fo�t�'�e validity of the information I have provided. .
�����;,;�' � � � � �� �
Signature'oi Licensed?l�mber kegi5tration 1�Iumber
�����l� '1 � ' L/ -.X L� I \B i
T}ne oi Registation Date
i recognize that ihis document shall become a pernanent record oi the aforementioned Public yVater System and that I am legally
responsitile ior the�alidity oi the infon�a�ion provided. �
� ,
Si;natu_e of Inspector Registcation Number
Ty,�e of Regish-atio� Datz
S!Yhite-Customers Copy � Yellow-Ciry's Copy ' � . Pink-l�pcnofs Copy