2016_0914 __ �., �� �{. � _ �R.,�
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�� ` ' 'T�as CommTssion on Environm�ental Quality
"'�-- 4�ustomerService Ins ection Certifieate
Name af PWS: Cit of Co el(
PWS ID#: Q57004q .
Lcscation of Service:
Reason for Inspeetion: I�ew construction..................
...... . .......... ......... ......... ...... ......... �,7.""
Existing service where confaminant hazards are suspected..........,. ❑
' Major renovation or expansion qf distribufion fiacilities,.................... ❑
I r� ' """ C� , upon inspection of fhe private water distribution facilities
: connected to the a rementioned publie water supply do hereby certify that, to the best of my
knowledge:
Com liance Non-Com liance
�
� ��,` ' � ��j No dir�ct cannectian between the public drinking water supply
� � � � and a potential source of contamination exists. Potentiaf
sourc�s of contamination are isolated from'the publie water
� ; system by an air gap or an appropri2���Clcflow prevention °'
� assembly in accordancewith Gommissl��tt�gufations.
F
� � (Z) No cross-cQnnection between the public drinking water supply and
❑ a private water system�xists. Wher�an actual air gap is nof
maintained between the pubJic water supply and a private water
� ;, supply, an approved reduGed pressure principle b�ckffow
� ; prevention ass�mbly is properly installed and a service agr�emen#
� : exists for annual inspection and testing by a certified backflow �Y
� � prevenfion assembly tester.
� ;: (3j No connection exists which would allow#he return of water used
; . � ❑ for conciensing, cooling or industrial processes back to the public
� ¢ water supply.
, (4) No pipe or pipe fitting which contains more than 8.0%0 lead exists
` � (� ❑ in priva#e water distribution facilit�es instafled on or after July 1,
E �< � � -� �� 1988 ar�d prior to January 4,2�94. " � �
(�} Plumbing installed after January 4, 2014 bears the expected
: = � ❑ labeling indicating <_0.25°�, lead cantent. If not properly lab�led,
� � please pravide written eomment. '�
(6) No salder or flux v�rhich contains more than 0.2% �ead �acists in
{� ❑ private water distribution facilities installed on or after July
� 1, ��88.
I further certify that the following.materials were used in the installation afi the private waterdistributionfacilities:
Service lines; Lead C7 Copper 6d""� PVC 5�" �Other ❑ �� ; ,,r,
Solder; Lead fl Lead Free C# Solvent Weld Q Other 0 �� ����+����a
,
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I recognize that thls daeument shall become� permanent record of the afarementioned Public Water System and
that I am le all res onsible for the validit of the information I have rovided. -
'' Remarks: �'� • . -
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Si nature of Ins �ctor: , .` Re istration Number,
Title: _ . � e of Re istration: ' � -,._ ��x�'`;% ��:�,���
Date: —
White—City Yellow—Customer Pink-Inspector �"
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