146 Washington (2)6f26J2015 1P9
CITY O C9PPELL i'ATF.R CT`1LiTIES
Cl'STC MER S RVIL'E iNSPEC3'IA:ti
Residrntiat ''j Commercial 0 T;"tCC IU#4S7QOA0
1- s."..__.._l.`-..,...—.__<u n usspe ior af the;?nti te a=atcr dssanbution facYlincs ia at c4>.
C.1hl e1__.v__,_..•which is ccranc4ted to the Cirv c,#CappeS!'ater S stem,da hesebe crrt f}
that,to tfic xst of rrAy knowledge.
In tion- ti A
i.ompldan e Cvmpliance
irett conre tian bct+seen the puhl c drinking w ter su spty arrc3 a -,osentra 3 L
sourre c f:or.raminadpn exisu. Potenfiai saturces of ec ntamina ifln are is latec!
from tl e pub4sc water sys em by ast afs gap or an appropnate backfI u prevent6ar
assembiy u:a cordancc ith Cammissian regu}ations.
2) 'v'a erass-cannect ora bchveen thc public inksng wacer suppiy and a privatz u ater id G
systeaz exists. L'}aerc an actual au gap is nnt maintained bctween the pubdic water
supplv ancf pnvacc a=aser supply, an approved reduecd prt ure-zonc backfl K
preventian assrstFbl}• is prerperly insstalled and a sen ice agrecment exists f r
annual uss.pettian and tcsting by a c ified backtlow prcvrntecrn de`°iee tes#er.
3) o connection exuu which would altow the recum of vvatcr used for c r densin B L7 7
cooIing or utdustnat processts back to the pubtic water sup afy,
f 4) !ro p pe or pspe fittang v•hicb contains rnz rr than 8.?°Ig Iead cxtsts izz grivart u a3er f. C7 C7
dystributson faeiiitres znstalltd on or after Iuf} 1, i9 8.
j Na solder os tlnx w}ic cnnt,inc mare tfian 2°Fn ieac3 exists u. pri+rate .-ater I II
distFibution fxc laties iisstallcd an or aficx lu7y 1, ;988.
Vi'trr sen'see shsH nos be pro nded or restoxed io thc jarirare wattr dastributicsn faciliti¢s;antil tht abo c eonciidons are detemuned to be
in compliancc.
I certify Lhat the followtr3g macerials v il!be nsccd in tht insta3lataQn aFthe ri ate aser dis ibutioQ factli ies lofated at_._._______.__
t__ t.n) c!z}kac the inspectcr+1 vaJiciate c€7rripliance durvsg thc in pcetion proe ss
vic leinesLeadL7CoppesvP`G 0 Gthtr 1 r'-
o1d r Lcad E Lead ree 'So?vent l els t cc [7
t rt ra ize th t this drxessr.ent sha3P A sc a petn nrrst rec rd af;3;r af'crezaer.ti nc'I'u isc L1'ater Systrm aad that 1 atn Ir al y
rrs sib3c f"or thc wal di z c,f#ac inlarmatinn I vr p.rrr i ed_
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w___.._____----____.____._
St,g na rc of Licensed Plumber eerscraEaE7 u ri r
U t 5`
Ty{+er Re s¢at r anc
3 rtc gnize zhat this d w»ettt shali becoFne a perrrzanent recard,f the aforecrs nte ned Put+l c'atz;Sy ssem and dhat 1 am treatly
respe yssibte for the alitiicy c*ft3te f rmatia prati id c3.
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0 1
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Signa rt of tnspcct r Re i,rati n't.r*t,e
r7 t S
Type of Reg n Date
W'4+1t-CuunmedcC.7 Fat3aW.f::ors sCc a Pmk-;mspee§er!aCIIp4
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