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Ci7S'�015�EF{SERYICE.fI�SPEC�'J,014
Residential �1" . Commcrcial C7 7`N12�C 7D�#05'7U040 �
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� �_ Gt�/[[� ,upo11 it�spectic�n of ths pm�ate water distribtt#iob faCilitiss located at . i �
-r��� /�o/�� /1 � wbzch is connected tn the City of Cagpe]!VJatcr System,do hereby certiCy �
: that,to the best of my knowtedge:
� • Tn Non- N!A �
Comspliance Car�liance �;
(I)� No direcf connection betwesn thc public drinlriug water suppIy and a potential �]� ' p q ��
source of contatrtinatiou exlsrs. Potential sources af cants�mination are iso7ated ' ' �
fram th� ublic water stem b au aur �"
1� SY Y };ap or an appropria4e hackfIow preventiott �
assemb3y in accnrdance with Com,mission regvlations. .
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(2) IJo crnss-connection between the pubIic drinkzng lvazer suppiy aud a privaie water I� p p
system��xists.�Si�here an ae4�1 air gap is uok maxintained betweea the pubIic evate� �
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snppl'y and gravate water sdppty, an approved raducecl pressnre zon� hackflow � L
, rei*ention assembl � �
p y is proparly utstalied and a servic� agreemerit cxis#s for
annu�l iraspectio�and#esfiug by a oe�ed back#laZv prevenk[on devica tester: �
(3) No connecdon exisis tiyhieh would aIIaw the retmn of water used£or eondensi�n� � p �
; aool'mg or iadustria}processes back to tfze pnblic wafer sttpply, �
{4) Na pipa orpipe fitting vrbich corttains mare than 8A%lead exisis in private watez ('�• q [] �
distri6ndon facififites installed an or after.7uIy I,1�88. , �
U�' �
�S) Na soider or flux w3aich confains more thau 4,�% lead exis�s in privatc waier �[Q • p �
distu'buaoa facSlities instaTled an oz�a#�er Juiy I,1388. �
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Water service sha11 natbe providad or restored to fhe private water disttihufion facilzdes until the above eanditions are detszucined to be
itt complizttca.
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I certi£y tha t the follo�-ing materiaIs Esrill 6e used in tha instalIation of the,pzivate v�atez dism'bution faciIities idcated at
`s/U �j_ v�Tt����� aud that the inspectar wiIl validate compkiaace ci�ning t}�e znspectivn process;
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Sorvicp tines Lead t7 Copper t7 PVC ' ❑ Qtlier �
Solder �.ead L7 �ad�'ree � SoZvehk Weld C7 Othar� r
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I recognize that this docvmenT sha11�iccoma a pezmaneut recoxtl of the aforemenfioned I'ublic Water Sysiczn and that 7 atn tegally �
responsx�b for the validity ofihe inEormati I have pr�vided.
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Sxgnalure ofLice' lambar 1t�isu=aii��.Number �
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Type ofRegisfrarion O�^ ��^� --� �``
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I recoguize that•this document shalI become a permanent record of.the a£oreYneAtzoned�'ubli�1�atex Syst�m ajnd tha#I am Iagally !��
respon�jSIe far tha validity of the informatio pravzded. f"
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Sagna(ure 4X It�pec[or R�sls�ati����bPr
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W S// s ���(�/�! ;
Ty�'rs of Kegishxtion ^ Date _ � �I`'
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