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lF���i�1���ia� � ��o�r�ne•r��a� � T1���'��ID k�157��3��
1 �'�.��j`�� ���' �I C.� , upon i�sp�ction oi i'_�e p�vatz `,i�ter dist�Sution iac;liti�s locatzd at
(�6� Rp�(� S �;,n , �v�ich ?S CJ�T-�PCL�d To the Cirij of�op�ell ls%atz;Syste�, do h�reby ce�iiFy
that,io the besi oi my lti�owledge:
� �Ion- 1�T/A
Co�pliance Co;�pliance
(1) I`�To dsect connectio� between the public d�-inscing water supply a�� a poten�al Y� ❑ ❑
source o= conianiaation exisS. i�o�ent-ial sources of contaminatioz are isolated
i on ii�e public water system by an air g2� or an approp-iate bac'nflow prevention
assenbly u�accordance with Corrli-nission regulaiions.
(2) No cross-coznectioa be2�,veen the publ_ic cLin,'cing vrater suaply a.nd a p�ivate water . � ❑ ❑
syste;7 exisis. Where an actuaI air oap is not maintained between the�ublic v�ater
supply and private w�ter supply, an approved reduced pz�s�ure-zo�e bacic�lou�
preventio� assembl_y is properly i�stalled and a servic� agreement e�sts ior
. a�ual inspection a�d testi�g by a ceriried backflow preven�ion device tes�er. .
.
(3) No connection exists whic3� would allow t�e retw-n of water uszd io� con�ensing � ❑ ❑
cooling or indusrial processes bacic to the public water supply.
(4) No pipe or pipe iiiting�,v�-sich contau�s�o:e than o.0%lead e;sisis in p�vaie��iaYer � � ❑
�istciburon iacilities instal_led on or after July 1, 1988.
(5) T]o selder or flux which contair.s more than 0.2% lead exists in p�ivafe waier � ❑ ❑
distr'bu�on facilities installed on or after Ju1y 1, 19So.
Water service shall not be provided or sestored to the private wzier dis�ibuiian faciLiies�til i.he a'oove condicions zre dete,_-mi�ed to be
s conFLance. �
I ce�-tify�hat e iollowing nzterials v�?ll be use in the installaiion oi the priva2e tivater dis�-ibu�io�iac�iiries located at
6� pG`� � f,h �� and that�e ir.specto�v✓ill vai;�q�co�npliance dun�g tb.e i�zspecrion process:
Service l��es Lead � Copper ❑ �VC � Other �
Solder Lead D Lead Frze ❑ Solt�eni Weld ❑ Other �,
I recognize u'�at this document shall become a pe�anent record oi the aforementioned Public Waier System and ihat I am legally
respo� 'ble for the validity oi the information I have provided.
�, ��, �.�' � � r � �
. Signature of Licensed Pl mber . kegistration NumbeF .
,�o��-� ��3� / 16 �
Type of Regis�ation Date �
i recognize that this document shall become a per.nanent record of the zforementioned Public Water System znd that I am legally
responsible for the validity of the inior�ation provided.
Signature of Inspector � Registration Nunber
lypz ofRegistratioa Datz
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