2016_0814 �
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cI'k'Y 4r c�PF�LY,war��t u�'IJLZTIEs
C[TS'Z'OMER SE�VICE�N�SPEC�'�,Ol't �
IZrsidential �" . Commcrcial ❑ 7'NI2CC XD f1U57p04D �
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I / ` 'l " '� � �/� upou inspecfion of the priti�ate water disixi6ution faciliries tncated at . �
� ��� _ whickz i�connected to the City of Coppall Watcr System,da hereby cer#iCy �
that,to the best of my knawTecfge:
' Tn Non- NtA �
Compliancs Com�rliance i�
(I)� No direct cvm�ectioa between tbe pablia drinking water supplg and a potan6al � • ]� Q a
source of cantamination exisis. Potentis�sour�es aP c�tumination are�isolated ' '
frozn th�public water system by an aur gap or an appropriaQe backtIow prev.ention ��
assembfy in accordance wf th Commission regr�latians. , �
(2) 3�1n cross-conneckion between the pubIic dri,nking watar suppiy and a pr9vaie-svater � D O
systam�exists,�1�lhera an ac4uil airgap is uot utaintained batween the�ublic water L
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supply nnd prsvate water sdpply, au approved raduced pressure_zc�ne bAekf�ow ' i:
, p�e'vention �ss�mbly is proparly instalied and a service agreement cxisxs for � �
annual ittspecfioaand tasting by a aerti#ied backflarv prevetttion device tester: �
(3) No conrtecdan exisis u�fucfi wauld a11ow the rcturrt of water used£flr condensin�, � � � `
; cooTmg or 3bdus�ia}grocesaes back to the publia water supp3y,
(4) No pipe orpipe fitti.ng svb,ich corttai�s more than 8,0%Iead exisfs iR privete watez ('�• Q d ��
distrihudan facilit�cs instaIled on or after.7uIy I,1988.
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{S) No solder or flux vrbich copfains more that3 Q,2°/, lead exis�s in}7rivate water �p � � �
dishn�ution facilzties fnstalled an orafter July 1,I988,
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Water service sha11 natbs provided or restored to fhe private nvater disttihufinn fac�ities until the above eonditions are deterurined to be �
iri com�iliattca, k
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I cnzlify that the fal]o��ing materials taill bs used in the installation of the.priva[e v�ater dism'bu�,on facilities I6cated at
���� �,��Pif,�h c;cJ�2 and that the inspector tvill validnte comp}lance d�riug the znspection proeess;
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Sorvrce lines Lead D Copper q PVC " C7 Qtlier�
Solder �.ead CJ T.ead�rea � Solvant Weld L7 Othez" ❑ �
a.
T recognize thatthis docvmettt shaTl bacome a permanent recozzi of thc aforementionad Pnblic Water Systczn and that I am Iegally �
responsz-b��for the validity of the informativs�T have provided.
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Sigua nfLi�e�, rI ber �egistiaiAu..�Numbet �
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Type of Regish�afion �_
Date
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Y secogaize thabthis doctuilent shall become a permancnt record of.the aforetnentioned.Pqbli�Watex Sysiem�ad tha#I am tegally �
responysijSIe f the v�lidity af the iufocmaaon pravid�d, �
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Signa[ure 0�jt�pector�� � �
Registratioz� bPr
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Ty�tc ofxegishxtton � Date . �
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WJu¢-Customdi CUPY Yelia W•Cit�s Capy Pidk-lasA��i�AY -
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