2016_0814 �
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CI'Z'Y or C��P�LL wnr��uTILZTZEs �
CZ7ST014�ER SE�YICE fNSPEC�'kOTti �
EZesidential [�1" . Commcrcial ❑ 'rNRCC SD{�p5ryp04D �
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I �, ` � _ /� o✓l�e�� �
- upou inspecfion of the gri��ate water disiribafion faciIities loca;ed at ; � �
— �S �y � �''► ���' � wbzckz i�connecied to the City of Gappell Water 5ystem,do herabp cez#ify �
: that,to the bast of my knowtedge; �
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� Non- T�fIA
Compli ce Carr�pliance ,£
(I) No d,irect crnmectinn trehv.cen th�ppblic drinkiug water supply and a patential � • � Q ��
source of contaminatioa exisLs. Patential sources af aoutAmination are�iso]ated ' ' "
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froru thc public water systecn by an air gap or an appropriaEe backfIow greveation
assembfy in accordance with Commission regUlations. , �
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(2) 3�10 crnss-connectionbetween thepublic drznking watar supp�y aud a pri�are watec � D �
systern�esists,�l�f�era an actval airgap is notmaintainad batween the pubIic water �
snpply and pzSvate water snpply, an approved raduced pressare zotte hae3tf�ow � �
, prei*ention assambly is properiy instalied and a seryice agxeement exis#s for � �
annuat inspeotios�and testing by a cerrifed back#]arv prevettlion device tester: �
(3) 1'+To Cotulecflan e�cisis�yhicfi wauld aI]ow the rctffrtt of water used£or condensitig �j/ � �
f coa�ng or tadusfria}procesaes back to tha publia water'supply,
(4) Na pipa orpipe fitting wb,ich corttains mare[han&,0°/a 1e�d exisfs i�priv�te watez {�- Q d �
distri6udan facili`tics iaslalled on or after•7uIy I,1988. �
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(S) No solder or flux vr3aich confains more thuu,0,2°/, lead exisfs in privatc waier • p, ' .. � �
distn'bulion facilities insta]]ed aa or after 7uly 1,198$. �
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Water service shall natbe prpvided or restored to ihe private vvater dist�iE�utinn faciliaes until the above eonditions are deteracined io be �
itt compIiarica.
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I ccrtify that the follo��ing tnaterials�ri1l 6e used iu the instalIation of the pnivace vra#ez dism'bulzon 2'aciliti.es Ibcated at �
�Su w','� �f S'�r aad that tha inspectar wi11 validute comp}lance during thhe znspectivn process;
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S�ice lines Lsad D Copper ❑ PVC ' d Otlier . . ,
Solder � �
Lead ta 7 ead Pree � 5olve�k Weld L7 Othez` ❑ ;
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I rec�o='e tharthis docvmant shzilliecome$pezmanez�t recoxX3 of the aforementionsd Publir VY'ater Sysicm and tl�t I atn Iegally �
responsxla�for�e validiry of thG inf'ormabian T have�rovided.
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Signature ofLice" tIpin ^ Ztegisuaii�.,.NumbeF <<
=J.3 /-'.�� � ' �._�Cl-/� �
Type of�tegistrarion Bate �
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C recoguize that•this docurnent shalI become a permanent record of.the aforementioned.pqb]i��VV"afex Sysi�m�ud that I am Iegally i�'
respon�ujSIe�tfie validity ofthe infacu�ation pravided, ";
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Signahue oS;it�pec[o Registraho�Ntunber �
C,�IS'�''S .� �/C/'/�
Ty�te of xeg�sh�atton ~ Date .
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WLi¢-Custiam�r.cupy YeElo�y-Cit�Capy �
Pidlc-1ntPCqa�t CaAY
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