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I y��.•���6,�' ��� ��� ,upon�Zs��CTIOIl flT i'_nz p�ivat� �V32E?d15t"il'J71r10Ii i�C111i7.�5 IOCdtZa 2T
6�� �,bv�.�. �9�/�t��(1� �_ , which is c�zmec��d to the Cirij of�o��ell ti+iater Sy;te_n, do her�by cerci�y
t�hat,io the best oi my lc��o��ledge: "
Ia 1Ton- N/A
Compliancz Coi�pliance
(1) ido dsecY co�eczio� '�etrveea the public drinjcing wa�er supply and a pocen�ial �< ❑ ❑
source ci conta��zatien exis�s. d�oieurial sources oi contami.naticn are isolated
fron ihe public water syste�by an zir gap or an appropriate bac'nzlow�revention
assenbly in accordance wiu`�Corrli-iissioa regularions.
(2) i�10 cross-co�necnon bervee�`�e pubi_ic 1��-in,'cing vrater supply�d a p�vace water . � ❑ ❑
sysie�exists. bVhe;z zn actuaI air gap is not maintained beYwe�n the�ubtic v�ater
supply and Nnvate water supnly, an approved reduced przssur�-zo�e bac��ou�
pre�✓e�iio� asse5nbly is properly i�zstallecl aad z sei�iic� agrez�enY e;asts for
. a�ua1_�spection zi:d testing by a ce:�izied back7low preve�tion devic�tester. .
�(3) No cor.nec�ion e;cis�s wich would alloui the retu.-n oi water used Tor co�c�e�sing � ❑ ❑
coo?ing or iaelus�al p_ocesses bacic to the public�iater sup�ly.
(�) �10 pipe or p;pe fi�iing�N1i�'ch contai.ns nore ihan o.4% lead z�„_is�s in private�;va7er � p ❑
dis�bntien faciliries installed on or ai er 3uly 1, 1988.
(5) T10 solder or flux which con�ains �ore than 0.2% lead exists � p�ivare wz�ez � ❑ ❑
� disfibutio�iacili�ies ius�lled on or a.ter 3u1y ?, 19oS.
V�Iater service s�al1_�ot'oe provided or�es�or�d Yo 1�-e private w�ier dis¢ibu�ion faciLrizs t�ntil"�z a'oovz co�dit�ons are de�e�i�ed io be
in conpLance. �
I c�=ify uiat t�e iollowin�naterials will bz nsed in�'�e installa�ion of the priva�:e water dis�bution fac��ti.es located z2
6 �3 �6 L� `�nf, t1��s ��. and that t3ie inspector v✓ill val;�te compliance dtuiag ihe i�saecrion process:
�t�.
r
Service l�,�es Lead ❑ Copper ❑ �V� ❑ Other �
So1�er ' Lead O Lezd ssze 0 ' Sol��eni We1d ❑ Othzr � '
I recoo ize tha�this docu�ent shall becone a az�anent record cf ti:e afor�inentioned�ublic tiVater System and that i an legally
:esAo� 'ble fo:the validity of tt,e i�ro?mation I have provided. .
���,..��,,�'� � � � d �i �
Signature of Licensed!1� mber ' Registration Numbei '
,��.������J � �Oa�l/��� .
Tyue oi Reg?station Date
3 recognize ihat t�'us documeni snall become a pernanent record oi the aforementioned Fublic�A/2ter System and ihat I am legally
responsitile ior the validity oi the inior,naiion provided.
, ,
. Sigaature of Ins�ector . Registration Nunber ,
ly�z ofRegis7atio� Datz
�Y.hite-Cusiomefs Coov 1'cllow-Cirv's Coov ' PiaS:•fasneaofs Coov