654 BridgeCITY OF COFPELL WAT R UTILITIES
CUSTOMER SERVICE NSPECTlOIti
Residential [,"' Commcrcia] TNRCCID#57U 44t
I A' npon itispecti n of the private water distribntiou facilitiss located at
v$y ''f which is connacled to the City of Cappell Water System,do hereby certify
that,to the best of my knawledge;
Non- NlA
Campliancs Compliance1) No direct conntccian between th$public drinking water supgIy and a potantial p
source of contami ati.oa exisu, Pofential sources af contamination are isolated
from the public water system by an aix ap or an apgropriate backflow prevention
assembly in accordance with Connmission regula ans.
2} No cross-cox nection bstween the gublic drinking water suppiy and a privais wafer D psystemcxists,l lher$an actnal air gap is not tnainiained between the public wat r
suppIy and private water supply, an apprbved reduceci pressure_one baekt w
prevention assembly is praperly instalied and a service agreement exis#s for
annual inspectionand tesfi.ng by a cectifed back#]ow prevenk'on device tester.
3} o connectian exists which wouId aIIow fhe rctum af water nsed for condensing p
cool'ug ar i tdns ial pracesses bark ta the public water suppiy,
4) No pipe ar pip itting which contains m re than 8,0%ead exisis iu private water p pdisihudanfacilitiesinstalledonaraftez7ulyI, I988.
S) Na soider vr flux v 3 ich coufarus mora than 0.2°/a lead e sts in private water I , .p• .. pdishxbutinnfacilitiesinstalTednnorafterJuly1,I938.
Water service shaIl not be provided or restored to fhe private water distribution facili,ues until the above eonditi.ons are determined to beincampIiance.
I ccrtify that tize follo-ing materials wiI}be used zA tha installatian of tl e private water distn'burion facilities lc5cated at
6Sy''<< and that tl e inspector will validaie coznpltaace dwing the iztspeciion process:
Service liries Lead Copper PVC p ptlier 5older Lead 0 I.ead Frea 'Solvent Weld f Ofher a
T recoo;'e that this document sha11 become a permanent recarti of tI a aforemeat9aned Puhli Water Sysiem and that I am IegallyresponsibforthevaIidityoftheinfotationIhaveprvided.
f tU
Si acure ofLice d Plumber Re istraiion,Number
t.p, i=s
Tyge ofRegistrarian Date
I recognize that•this documcnt shali become a peimanent record o'the afaremeutionod Publi Water System aad tha#I am IegalIyrspon le for the vatidity nfthe inforination provided.
Signature ofI pector Registration Number
7-/ A`Type fRegis-atian Date
Whia-Cunomett Copy Ye[low.Citys CapY Pinfc•fasPwa s CaBY