2016_1010 �'�`�'�� �T';��JFP:� �J i �i'�:�7'�J�rr 7�ir'7ZI:1?'=,�
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�I �,�%I!' l'/�� ll`�' �/ U ( , ll OR Lz15��C�lO:I 'J:� `L'�1` ;1:'�'' b "_ r
� p c� v3zc� dist-ibutian d�c;li��s ]ocated ai
�' � bb 0� �k1� ��. , �,�ihicl� is ���eci�d to �I�e �Cit�� �f�oN�e�l tii�i�tz; Sys2e�, cio hereby cei�i y
tha2, io 2hz best oi my lti�o��vledge:
�� �Ton- �i/A
Co�p�ianc� C��pli�.,ce
(1) i�io d�ecf con.neccio� '�eh,veen the public �rin?cing wzte� su;�;�ly ancl a �oc�n�ial x�� ❑ ❑
source cf coata�-ninatie� exis�s. �o�e;�eial sources of ca�tami�-�aticaa are isolated
iron�he public water system by an air ga� or an appr��ri�te�ac�cflo��✓�:eve�tion
assem_biy i��ccordance with Co;n��ssion regulations.
(2) �'10 cr�ss-coi�nection bec�vee�u�e pubi_ic 1�,-in,'cing v✓z�er sta��ly��1 a p�iva��e v�izrer �" ❑ �
systea-n exists. VU�e-� an actuaI ai�;ap is not n-iaintained be�een fihe��bl�c water
su.Pply and �nvate w�ter supnly, aa� ap�r�ved reduced pzesstir�_�3,�v �acic�ou�
p�even�i�� assembl_y is pro�erly i�zstallee7 and a ser�ice agrez�ei�Y exists �or
�.��ual sispection�nd tesY��n_g by� cr�zi�d bac�7ow p�eve�iio�de��ice�es�er.
(3) No con�ection er�isis �ha.cn �✓ould allov.� t�.z recul� oi water used �oP co�c�ens�g � � �
cocli�� o�u�dustsial pr�cesses back to tihe public��ate�s���l;.
(�) !do�ipe o,-p;pe rl�iing �vich ce�atains -aore than o.0°/o lear3�xisis in p�v�ie ��ia'rer �� ] �
dis�ibntion facilities insf�lle�o�o_r a_fter 3ulv i, 1988.
(�) �10 selder o? f1u� wh.ich con�a�,�s ��ore th�a 0.2% lead exists ��z ��iva'r_e �vzYer � 0 �
disfibution facili�ies installed on or ai�er 3ui_y 1, 19So.
d1Tc.'ief SPP/iC2 S�c�ll IlOi De�JIOV?G�2�OI`�SiCSs,L7 YO �e�S1V3��'4�I�.i��C�SS`Q7�11C1a�1 i'�C1,��ZS LTL`�Z c10GV2 CO�CllL?OIlS 2.I.� CeiE;_'�i71��C1=0 be
�n CO�L11aIlC�.
I cr��.ify�h�t�he`ollowino n�ieria�s will oti used in�e installa�o�oi t�ie priv��rz vuafe�dis�ibu�on iac;1_ities ]ocated zt
�S� �•,� ���� and��a2�3iz i_as�ector vvil?valicLat;:con?�l:�ce dur�o �,;i�s�ecrion piocess;
Se�iice l,sies Lead � Cop?e: ❑ �VC ❑ �ther �
� Solder' i ead � ?ead�rree � Shcve�i�✓Veld � fl2Ler � • y
I recoo izz that 2nis docurnenT shall beco�ne a pe_�;nanenr record cf t'cz aforeTentione�_+�ublic yUatzr 5ystzan�r_d tha2 I a�le�ally
:es�o� ble for the validiTy o���e info:nation�have pro��ided.
• � '' I��a�I� ., �� � � �
� �. ...�� ,�� � � � d �,i �
Signature of Licensed rl m'oer ' kegistration�iumbe:
,/� �
°`��'�� 11��_1D e �s�
i y�e oi Reg_station Date
i_recognize ihaT This document snall become a�er-nanent record oi the aforementioned Public W�te:System and t�at I 2m legally
responsible ior ihe validi'ry oi t:�e L�iomation provided.
Signatu_e oi I�spector 1Zegistr2tion[�tunber
i y�e of Registratic� ��qz
�Nhite'-Customers Copy yellow-Ciry's Copy . PinY-lnspenofs Copy �