2016_0814 �
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C[.TS',i'OMER SERVICE fINSYEC�'kOI4 �
Residential �" Commcrcial ❑ TI`IRCC ID f1057p04D �
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I O ...� Q,1J i ' l • upon inspecfion of the pm�ate water distribufiot�faailiaes tocated at , �
� � U i � � _ whickt is c�nnected tn the City of Cappe]I Watcr Sys#em,do hereby cer#if}� �
: that,to the best of my kuowtedge:
� � Trz No»- N!A �
�ompli s Com�pjiance ;;.
(1}• TJo direct connecdon betv�een ths public drinJ�iug water supplp and a potan6at � ' �► ❑ �
source of contaminati.oa exisis. Potentia�sources af aozitflmination are'iso]ated ' ' u
$am the public water system by an a'u gap or an appropriate bacicEiow prevention
assembfy in accordance with Commission regvlations. .
(2} No cross-connection bekween the gublic drinking wator supp�y aud a private water !�'" ►� p
system�zYists.�Whera an ac4.ui1 a'vr gap is not maintaiued berweea the pubIic watex
snpply and private water sappiy, an approved reduceci pressare zon� haek�ow �
, pre'vention asscmbly is proparly instalied and a serVic� agteemerif cxists for �
annuat ipspactioaand#asting by a cerri#ied backflaSv prevenk�on device tester: �
(3) No connecdon exists w�uch w�uld aIlpw the rcturn of tivater used for condens�n� � [� �
4 cool'mg ar lndustria}procesaes baclt to tha publiewafer'suppiy,
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(4) Na pipe orpipe fitting vrb,ich eorztains mare[han 8.0°/a lead exisis i�przvate watez �• q p �
distrihudan facih'ties insfaIled att or after.7uIy I,1988. ,
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(S) No solder or fiux rv3aieh eoufains more th�w 4.2% lead exisEs in private water �Q � p
distn'bufronfacilities iasta7led aa orafter July 1,I988, �p
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WaYer service shall natbe prctvided or restazed to the private wat�r distti�trtinn facilzaes until the above eondi.tions are deterr�zned io be
in campliattca. +
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I ccttify that the follo��ing materiaIs tvill 6e used iu thc insfallatian of the,grivace wa#ez dism'butzon facilities Ibcated at
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v and that the inspector wiI1 va�idute comp�lance dur�g the znspectivn process:
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Service[iaes Lead D Copper ❑ p^�T� - ❑ Q�r �. '
Solder Lead L7 S,�ead Free � Solveuk Weld [7 Othar ` Q F
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I xecognize that this docvme.nt shall t�ecome a pez�manebt recazd of the aforementioned Publio Water Systcm and that I am Iegally £
respons��r fqr�the vaIidity ofthe" �nTfiave provided.
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Sigttature f T.ice� �lnmber lt�isaaii��.Num eF �
L�J S /' S' ' �--/�/�� - �
Type o�'Rcgssfrarioa Date
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I xecog'nize that�this docurnent shall become a pemianent record of.the aforeweutioned�'ublic'Watex System�nd fhai I am tegally Y
respon�SijYIe or the vulidity of the iu�orma6on pravzded. �'
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Signa[ure ok_It�pecto Registratio b r �
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Ty�se ofKegis�aation �°
Date . �
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Wlu¢-CustoM ti CUPY YcEIoW•City�Capy Pak.InsPCqafSC�AY
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