641 SpringlakeCITY L)F CQPPELL WAT R UTILITLES
CiJSTOAIER SERVTCE NSPECTIOlti
Residential Comrncreial 0 TNRCC IIl#057U0401
I f' `' ~y' ` upon inspectic n af th$ rivate wa€er dis ibufion faci i 'F ss aca[ei xI
r`— wkuich is connecled to the City oi`Cappell Wafer 5ystem,do hereby certify
that,Eo the tsest of my knawledge:
Tn Non- A'!A
Compliancs Comp3ianceI) No duect connection between Yhe public drinking wat r suppIy and a poten ia p p
source of contamivation exxsts. Pofential sources of contamination are isolated
fram the public water system by an air ap r an apgropriate backflow greverrti.an
assembty in accozdance with Commission reg lat ons.
Z} No crass-connecsian between the gu6Iic drinlring rater supgiy aud a private vvater p
system exists,l lhere an actual au gap is nof maintaIned between the public water
supply and private water supply, an appr ved reduced pressure-zone backflow
preventian assembly is properly instalied and a service agreement exists for
annual inspectioriand testing by a certi ed backflazv prevention device tester.
3) No connectian exists zyhicfi wauld aIlow the rctum of vater used£or condeusing QScooI'mg ar[dns zal processes barlt to t4 e public vater suppIy,
4) Na pipe or pip fitting which conbins more than 8A%ead exists in grivate watez t' - p pdistributionfacilitiesinstaIledonaraftexTutyI, 1J88.
Na solder or flux v bich coafains more thaa 0,2°/a lead ex.ists in privatc water p pdish-ution facilities installed on or after Juiy I,I98$,
Water serviae shaIl not be provided or restored to the privafe water distcibutian facilides until the above eond tions ara deteRnined to beincoznpIiance.
I certify rhat tl e falla ing materials wilT be used iu the installatian ofthe grivate water dis ution faciI ties ldcated at
and that the inspector tvili validate compliance during the inspection process;
Service tines Lea,d Copper O PVC Otlier Solder ead C7 L,ead Frea `Solvent Weld Cf pther
I recagnize that this document sha11 become a permanent record oftIie afnremeatiancd Fuhli Water Sysiem and that I am Iegallyrsponsibforthevaliiityot'the information I hav provided.
Signahue af Lice d Plumber Registration.Number
v//6t S
Ty e ofRegisirarior Date '
I recognize that•this documcnt shall become a permanent record ofthe aForementianed Public Water System aud Ehat I am legallyrespon ' le far iiia vaLidity afthe inf rmabon pravid d.
Signacure ofI pectar Re istration Number
i J r ', --/5TypcofRegis-zfion Date
Whi¢-Gasomc Cupy Ya[fow-CitN.t Copy Piok•InspMa sC.nFY