455 Twin Pine Ct3'T`1 aF JPPLi;I, '`;:T;s!,?JTILI;I
CbJ T L I'/I'F 5i+flc!;lIJFE;'l l
Il 9g 1 4a L o rr,n r T1i'r'II#O 1 D
i pon inspection f t'ne p,ate ,v ter distribu7 an aaciliTies located at
l S5 l v.V1 p,e Cvvr. vhich ?s co ected To Yhe Citj of Co ell riater Sys2en, do h;.reby cercify
that,to the best oi my knowledge:
Non-N/A
Complianc Coinplia ce
1) No direct cannection between the public drin:cing water supaly and a ,o2en ial
source of contamization exists. oiential sources of contam,ination are isolated
from the public water systzm by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
2) No cross-connection bet-vveen the public drinking wa er supply and a private wa er .
system exists. Where zn actual air gap is not maintained bet,veen the ublic water
supply and private water supply, an approved reduced pressure-zone baclLlou
prevention assembly is properly installed and a service agree;nznY exists for
annual inspection and tesYing by a ce.fied backflow preve iioa device tester.
3) No connection exists whicl would allow the return of water used fo: concensing
cooling or indus ial processes bacic to the public water supply.
4) 1Vo pipe or pipe fitting which contains more than 8.0% lead exists in pnvate v aYer
distriburion facilities installed on or after July 1, 1988.
5) I 10 solder or flux which contains more than 0.2% ]ead exisis in private vva er
distriburion facilities installed on or a ter July 1, 1988.
Iater service shall not be provided or restored to the priaate water d.istributian facil?ies til the above condic ons are deter_niaed to be
in compliance.
I certify that the following materials will be used in the installai on of The pnv te vater dis-ibution faciliries located at
6 55 w•1. p 1 (.,r , and that Yi e iaspect r will vaiidate compliance during the inspection process:
Service lines Lead Copper PVC Other
Solder Lead Lead Free Solvent leld Other (
I recognize that this document shall become a permanent record of the aforerraentioned Public Water Syscem and that I am legally
respo 'ble for the validity of the information I have provided.
Signa re of Licensed PI mber kegistration Number
5-r 16 / s
Type ofRegistration Date
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Number
Type of Registration DaYe
9+'hite-Cusiomers Copy Yellow-Ciry's Copy Pinh-laspeaors Copy