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CC7S�'OMER SER.VICE f1��SPEC�'k014
Residential � Commcrcxal C7 I'NR�C ID�#�57p04D �Iw
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j GZ I't� upon inspecficzn of th�grivate water distribation faailiries tocated at . � �
�'��� � � whickz is canneoted tn tha City of Cappell WaYcr Syskem,do hereby ceztify �
: that,to the best of my knowledge: �
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' Tn Non- NtA
�om Ip iance Carr�Iiance iF
(I} 7Jo dizecf cannection betrv.een The puhlic drinldug water suppIy and a potEntial � ' � �j :
source of contamivativa exfsrs. PotenbaX sources af aautnznivation are isolated ' ' �
&ozn thc public water system by an aix�ap or an appropriafe backfIow pzeverrtian �'
assemb3y in accordauce with Coztxmission regvlations. ,
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(2) No crnss-aonnection between fhegubIic drinking u�atar supp�y aad a privaie wa#er �J' � p
system exists;Si�hera an ac4.�1 aiz gap is nof m�intainad bstweea the pubIic water
supply and pravate water sdpply, an approved reduceci pressare-zon� haekflow � �;
, pre'ventiou asscmbly is properly iusialied and a s�ryice agreemenf nxists for �
annual iuspeafion.and#esfing by a ce�ad back#lativ prevention$evice tester: �
(3) No connecdon exisis w}uch would aIIow fhe rcturn of�vater ased for condensine
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; ooaI'mg or'sndustria}processes baek to tha publia water"supp}y, �
(4) Na pipe arpipe firiing v�hich coz�tains mare[han 8.0%lead exisis iR private watez �• q d �
distri6udan facih'�ies insralled an nr after.7uIy I,1988. , �
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{S) No solder or flux vt#ich copfains more thar�,4.2°/v lead exists in ptivatc water •p - p �
disfu'buktonfacilzties instaTledaa or�er7uly I,I�88. (;
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Water service shall natbe pravided or restored to ffieprivate water disttihufion facilides until the above ennditions ara deteruAnedzo be �
itt compliance.
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I certify that tbe follo��ing materiaIs�rill 6e used iu the installation of the pzivate vra#er dism'bu�ion facilities Ibcated at
,��,/ T�//►7'n a o/� aud that the inspectar wviIl validate comp3lapce d�nittg tha znspecrion process;
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��ervice[ines Lsad D Copper CI PVC ' Cf Qtlier �, �
Soider Lead L7 X,ead�ree � Solvaut Weld [J Othaz _ Q `
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I recoo i�e Yhat thi9 document shz111iccome a pezm��nenf recozr3 qf ti�c aforementioned Public Watee Systom and that I am Iegally �
responszl� for the validity of the infornzatzon T have provided. �
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Signahu�e of T.ice� amber �t�isuaiA�.,•Numb�F ;
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Type of�t.egi5lrarion Date
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I recog4ize that ihis docurnent shalI become a pecmanent record af.the aforeazeutzoned k'ubli�Watex System and that I am fegally `
r�span ' for the y�tidity of tEzc info yz��„
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S�gna e ectoi Re�istration I�7uznber � >`
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�'y,po ofKegisiration Date . '"
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