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CiTS'�OMER SERVICE fNSPEC�'kOl4 �
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Z �'`/9�� upos2`Ynspecfion of the priti�ate wa[er distributiou faailities located at . � �
� whzckz i�connected tn tfie City of Gappell Water System,do hereby cer#ify �
: that,to i(te best of my knowledge:
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. • �
� Tn Non- N!A S
�ompliancs Corrt�liance ;;
(1}• No direcf conrtectiou betFv.een the public drznJring water supplg and a potantiaI �f ' � q k
source of con{amivatiott exisrs. Potentis�sources af cozctumination sus�iso]ated ' ' �
fram thc ublic water stem b an.air E'
1� S7' Y �.p or an appropriafe backEIow greventian
assembfy in accozdance with Com�mission regulations. . �
(2} No cross-aonnection betweea the gubIic drinking v�ater supply a¢d a pnivaie�svater [�'' p p
system exists,WI�tera an ac4.�1 au gap is notmaintained batwaen the�ubIic watex
supply and private vuater snpgly, an approved raduced pressnre zc�ne haek�ow � lE
, preirentiou assambly is properly instalied and a servic� agreemenf cxis#s for �
annual uaspoction and tesfing by a eertified bacic#]arv prevenlaon device taster: �
(3) tdo connecrion exisfs which would aIIQw Che rcLurn of�vater used f�r cnndensin,� �% p �
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i cooI'mg ar indus�ia}groces�es bar,St ta tha public waeer'suppiy, �"
{4) No pipe orpipe firiing which eorttains mare than 8.0%lead exisis iu privete watez �• �j [] �
distrihudan facilitics instaIled an or a$er.7ufy I,I988. , �
(S) No solder or ftux w}aich contains more than 0,2°/a lead exists in�srivate water �p • p �
distrx'bukion facilities instaTled an or a#ter 7ul y I,I988, � �;
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�ater srxvioe shall natbe pravided or restored to fhe private water disitihutinn facilzdes until ihe above eondit'tous are deterr�zned io be �
in cam�iliance. 3
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I ce�tify that the follo��ing rials�vill be sed in the inataliation of the pzivate vra#ez tii'sm'buti.onfacilities I6c�ted at
�� � `F�� aad that the inspectaz wiIl validute comp}lapce d�riug the znspectivn process;
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Sorviee[ines Lead ❑ Copper ❑ PVC " C7 Qtlier �'
Solder Lead q �,ead�ree �' Solveut VTeld C7 OtFiar Q �
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I recognize tharthis docvment sha11 tiecoma a pezmaneuf recos�7 of the aforament3oned Public Water SysTem and t}u�t I am iegally �
responsz�b��for tbe validity of the inE'omzatzon I have provided.
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SzgnaEura of Liae� mbar �tegisffaiA��.Ntumb�F �
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Type o#'Registrariou Date '
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Y recoguize that•this docurnent shalI become a penuanent record of.the aforernentioned�ublic Wafex System and fihai I am EegalIy �``
r�spon�ij}Ie for tha validity of the infona�ation pravided, ;,
S2gna[ure Q�ec��� - ��� . i
Re�istratiozt Number �
Ty�s o�d�..�t=�� ' Date /D �� 7 �`� '
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Whi¢-Custom�i CupY YaElow-City's Capy P�•t�cb�=��Y
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