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CITX OT CaPF�LX,WA.T�It UTIT,I'I'IES �
Ci7S'�Oh�ER BE�VICE fPfSPEC�`�014
Residential � . Commcrcial ❑ 'I'NRCC ID fIQ�7i304D
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I upotz inspection of the private water disffi6�tiou faailities located at . ; ;
� 'fs E r'�pr �ti ` wbich is connsct�dtn tha City of Cappell Watcr System,do hereby certif�
: that,to the best of my kttnwTedga; �
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' rn Non- NtA ;
�ompliance Corrt�pliance �
(I}• No direct cannection befween thc�rublic drinking water supply and a potential • �] p �
source of contaminatipn sxists. Pote,ntaal souroes af cazztAmination are�isolated � ' ' �i
fram the public water system 6y an air�ap or an appropriatc backflow pxeventian �
assemb3y in accordance with Comniission regvlations. , �
(Z) No cross-eonnection betweaa the public drink.ing wazer suppiy aud a privafe 3vater �"/ p 0
system-exists,�1�hera an ac4uil ai�gap is not utaintaLred betweea the pubIic water `
sn 1' and pp y pp p • ``
pp y private water su I , an a roved reduced ressnre-r.one baokt�ow� i
, pre'ventiori assembly is proparly iustalied and a seryice agreemerit cx�sts for
annual iuspeotio�and#astin�by a certified backflo�v prevettkion device taster: �
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(3) No connection exists which would aIIow the rcturn of water used£oz condensing ,[� � � �
s 000�ng or Ladustr�al pror,esses back ta tha pnblia water suppiy, �
(4) Na pipe orpipe fitting�hich corrtaiz�.s mare than 8,0%lead exisfs i�private water �• � � �
distrihutian facilities insralled an or aftes 7uty I,I988.
(S) No soider or flux vJ#ich eobtains mora tha� p,���, lead eYists in}rrivatg water � �p • �
distu'bnaon facilzdes instal]ed an or a#}er 7uiy 1,I988,
yr .
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Water sesvice shall no}bs providad or restored fo fhe private vvat�r dist�tibution faciliries until the above eondilzotts ate detezArined to be
'ra campliance.
I cettify thaE tbc fol]o�-ing materiais�rill 6e used 3u the installation of the.privaee�va#ez dismbu�ion facilities Idcated at �
S b o��e /�r'� aad that the inspector wi.i1 validnte comp)lauce ci�ing the znspecticm process:
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S�eivice lines Leac[ O Copper tl PVC ' ❑ Qtlicr�
Solder I.ead LI 7.,ead Fzea �'' Solvet�t Weld C7 �thex - p !;
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T recognize that Yhis document sha711iacome$pezmanenf record of the aforementianed�ublir Water System and that Z am Iegalty �
zesponsx�b��for the validity of ih�inf'ormadon T � providad. �
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Sxgxahzre_ Lice� d ar Ite�isuaii��.NumbeF �
GJ� s � /�- i y�-
Type ofRegisfiafion Date ' �
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I recognize that this docurnent shalI becorne a parmane ecozd of the aforeraentioned Pnb]ic Water System�nd that I am tegall� �
respon�,ie for tfie validity of th.e info�zrcation • ed,
��� t
Signatt�re p�; pectar Re�is(ratiou Nuznber � �
Ty�so ofxe�h'�a sot �� " . /�� — 6 �
Date . �;
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WLitc-Customrls CVPY YcltoW-Cip/s Capy � ',;
PidF•larPtetw'1 Copy �;
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