657 Canterbury (2)CITY QF COYPELC r JATEIZ UTILITIES
C IST MER SERVICE N SFECTIOlti
Residentiai [" Commercia! TNRCC ID#D57f 040f
I f/ f `f"`r ,`'u on ins e t3Qn af the rivate waterPpr d s but sn facilinss lEc tGd at
S7_ C"'L r 'which is connected to the City of Cappell Watcr System,do h reby certify
that,to the best oF my knawiedge;
I Nnn- NIA
Compliance Campliance
I Na dxrect coniaectiun betr,v.een Yhc public drinking water supply and a patenEial f p p
source of cantamination exists, Potential sources af contazninaticzn are isolated
from the pubiic water systern by an aix gap ot an appropriate baekflow greuerrti.on
assembly in accordance with Conamission r gulat ans,
2} No crass-eonnection b tween the gubIic drinking water suppIy aud a privaie wates Cs" D psystemexists,IItere an actual aiz gap is nof maintained between the pubiic waset
suppIy and private water svppiy, an apprflved radt ced pressure-aone backflo
prevention assembly is properly instalied and a service agreement exists foz
annual inspectionand testing by a cerri ed backflosv prevenkion device tester:
3} FJo connecrian exists which wou3d aIIaw the retum afwater used for condensin
cooling ar indnstrial pr4cesses back to the publ.ic vater supply,
4) Na pipe nrpip ttFing which contains mare tfian 8,0%lead exists in private watez p pdisibuaQnfacilitiesinstaIledonoraffir]'uIy i, 1 8$.
S) Na solder ar flux w ich coAtains z,,are than 4,2°/a lead exists in privatc water F/ p pdistn`bution facilities instaned an or afier July 1,I98$.
Weter service sha11 not be pxovided or restored to the private water disi ibufinn faciliries vntil the above eonditi.ons aze deteim.inad to beincanzpl%ance.
I ceztify that the fallo-ing rnaterials rit3 be used in the installatian of the private water dism'bu#zon faciIities ibe ted at
S 7 J +°
and that the inspector wil validate compli3nce dvri g the inspecrion pracess:
Service li es Lsad Copger 0 PVC p Q r 5ulder Lead Z.ead Fr e ' Solvent Weld Cf Other Q
I recagnize that this docvment sha11 become a permanent record of the aforementioned Public Water Systezn an that I am legallyrsponsibforthealid.ity ofthe inEonnation I have provided. J
f tIJ
Signature af Lice d Plumber Registratzoa NumtaeF
P
Type afRe astrarion Date
X recogxkize that•this d curnent shaI1 become a permancnt record of.the afarementioned Public Watez 5ystem and Eha#I am icgallyrsgon ' Ie for tfie validity afthe infaririafion praviri d,
Signacure qfI pector Re istratioa Nvmber
S r -/
T'ype ofRe isti-ation Date
YJhi¢-Customers Cupy Yalfow-Cit s CaPY Piok-lasycdofs C.nAY