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Residentia[ [�" . Commcrcial D T'NkCC ZD f1057a04D
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I � � �c 'v upot2 izispecfion o�tha prit�ate water distrihtifiop faaiIities locaied at . � :"
� �Q�1 �vA f�ile7`'an � wbiclt zs connecf�d to the City of Gappel[WaPez Sps#em,do hercby certif� �
: ttzat,to the best of my lwotvTedge; �
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�ompliance �arr�Iiance i"
{i)� No direct cosmectfon bet�v.een T.�e pubIic drinking water suppiy and a potantial (y ' p q �
soume of cantamiAatiou exisis. Pot�ntiaX sources af aoztt�;minalion are�isolated " ' �
from the�sublic water system hy an air�ap or an appropriate backfIow pzeventian �
assemb3y zn accozdance with Com.mission regvlations. .
(2) No cross-aonnection batweea the pubIic driukizag wazer suppiy and a privaie vrater �" p p
syst�m�e:cists.�SVhera an ac4uil airgap is notmaintained betwean the�u�Iic water <
supply and private water snppty, an apprflyed reduced pressnre-r.�t�� back�ow � �
, preventioit assembly is properly instalied and a service agreement cxisis for � �
annual iuspeeiion.and#estin�by a certi#iad back#]aw prevenkron device tester: �
(3) P+to contlecri�n e}cists which would aIIow khe rcturn af water used£nr condensing
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; coo�ug or iadus�ial grocesaes back tv the pnblic water suppiy,
(4) Na pipe arpipe fitting tv�tich cor�tains mare tt�w 8A°!o lead exisis in przvete watez �- p p �
distrih�.tion facilities instaIled an or afcer.7uly I,I9$8. , �
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{S) No solder or flux �vhich coAfains mare tha�t p,2°/, lead ex[sfs in�Srivafg waier � � Q. ' ., p �
distn�bntion facilitits instalTed aa o��fteY 7uly 1,I988.
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Water service sha21 rtatbe prpvided ox restored to ffie private�vater distrihutian facilides until the above eonditions at�detena�ted to ba
itt campliatzce.
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I ccrtify tha t tbe follo��ing tnateriaIs�vill he used in th�installafian of the�rivaee wa#e,r dism'buti,on facilities I�c�ted at
'�G�� /��•�r`•' 7`� aud that the inspector will validute coxnpJlauce d�ing t3ie s.nspecrivn process;
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Servica tiaes Lead D Copper !a PVC ' d QtU.er
Solder I..ead C1 Z,ead Frea '� Solveut Weld Q p�� p �
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I recognize tbatthis docnment shall iiacome a petmaneu recoxri of tfke aforementioned Public Water Systcm and that 7 am Iegally �
responsx���for the validity of ihe information I provided. �
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Sig�aiure o.fLice ' lumber �.2.egisaaiiv�.Num6eF �
G�sr�s � �_�l_ . �
TypeofkZcgisfrafion Date ' �
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I reco . �
gnize ihat this doctuineni shall beoorne a pecmanent recozd of.the aforerneutionad Publi�Water SysCem and thai I am legally �
r�spon�j5Ie for tha validity af thc infoimabon praviclad. k:
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Signattlre q�;� pector Re��stratto�Nusnber �
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Type o egis4�fio Daie r I?
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WLi¢.Cusiomds CvaY Yaltow-Cip"s Capy Pirik-1nsFxfw's Capy F;
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