701 Rock Springs (2)T l F f PPLi1,;;-7'?J'TILI il?'
C J'I'cL il'i°Y 't1 I'i;'L'T:1
F 1 a . aa r,nPrs Z'l 3?'ID #D flD 1 D
3 Pi i upon inspectio: t i the p vz2e ,va8er dislTibutian facilities ]ocated t
70 ( Oei4 J1 yih C Rr u.e. , dvhich is connect d to the Cit of Co,e31 s%ter System, do hereby cercifyU
that,to the besi of my knowledge:
1Von-1/A
Cornpliance Co pliance
1) No disect connection between the public drin:cing waYer supply an a o2en ial p
source of contarriination exists. &'oiential sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regulations.
2) No cross-connection beriveen the public drinking water supply and a private warer
system exists. Where an actual air gap is not mai tained bet een the public water
supply and private water supply, an approved reduced pressure-zone bactt lou
prevention assembly is properly lizstalled and a service agree nent exists for
annual inspection and 4esting by a certified backflow preve ti n de ice tes2er.
3) No connecrion exists whicn would allow the return of water used i i concens n p
cooling or indus ial processes bacic to the public evater sup ly.
4) t Io pipe or pipe fitting dvhich contains more than 8.0% lead exisis in p vaie vaYer p
distribution facilities installed on or after July 1, 1985.
5) I 10 solder or flux which contains more than 0.2% lead exists in private vater
distribution facilities installed on or after July 1, 1958.
later service shall not be provided or restorerl to the priva4e water distributian facil?ties until he above condi ons are eternzined to be
in compliance.
I certify tha2 the following materials will bz used in the installaiion of the priya?e,Uater dis ibution faciliries located at
O b i h l(1 C` I o a, and that 23 e iaspec2or will valiciate compliance during the inspecYion process:U
Service lines Lead Copper PV Other
Solder Lead Lead Free Solveni Teld Other
I recognize that this document shall become a permanent record o the aforerrbentioned'ublic Water System and that I am legally
respo 'ble for the validity of the information I have provided.
9
Signa re of Licensed P] mber kegistration Number
a5 l b /IS
Type of Regis ation 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 t\'umber
Type of Registration Date
hile-Customcts Copy Yellow-Ciry's Copy Pinic-Inspeao s Copy