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2016_1109
�3�'~I �F��JPP,�,1 r�;�����;�7'�J��1��i 1LI;1 i.;� ��Zi;�1!�1/�'_�i'e'I+�iJl'�c? �1 1"�;�i'�:`T'7'�1 �����cl�rri�.i �;, G���n� ��;7� � =it��?�'� II� �����DD�J�� �� ,�- ' �I�I I 1������� ��^�� �l�' 'v d u� -----, u��n i�s�,:c:ion �f��e p-i.�a:� �,v3,ei dis�ibui;an f�cili�es loczted at 6—1 i �OG�I ��/1 S r�` , dVd7?C_1 ?S �O�,PCi�Cl t0 li14 �iT�j oi�o��ell ?i�iater JyS�eS�� C10 t'127i,b f Cercify ��at, io �he besi of ny lti-�o��ledae: �,� �1on- N/.A Co��liGnc� Co�pliznce (1) i�±o ��!'ecY connection ?�eh,veen the publ_ic dnr�?c�g waie: sunply and a �o2�n�al y�� ❑ ❑ sou.ce cf contz���atie� exiss. 1?o�enY:ul sources oi contarr��aticn are isclated iI01i1 i�1e jJu(:IIC Wdi2i system by an air b27 07�-� appropria�CP�r1C;�ZO�N�7i�VPfli3OT� assenbly i:� accordance wit�'�Co�-�-iissie�regulaiions. (2) 1�10 c_oss-coznection be�vee�u'�e publ_ic �isy'cing wa�e�sup�ly a;�d a��va��e warer "� � �J sysTem exists. �Uhe=� 2n actual 2ii;ap is aot mzi�tai,�ed ue¢w,eex�the�ub1�c y✓ater supply and ,�nvaie wzter sup�ly, an a�proved reducUi� T�I2SSll�-Z3�� Lacl:tlou� pre�✓en�io� Qssenbl_y is pro�erly i��stallee� and a se�iice a�re�-7e�Y evisis ror a�ua?�spection�.�d 2es�,�g by a ce�izi�d�actir'�ow prede�iia�de�/iC�czs�er. (3) i�10 cor.nec�ion exisis �rv�ic'� woudd allo�i t�z returr_ oi ti�a�er used :o_ c��ce�sa�g � � ❑ cool_��o:u�dusLial p:flcesses bacic io t�e��ubi1C 4�/S[er SL��,ly. ��r� 1'do?ipe or�ipe 7iitL�g }�v�icn coniau�s-zo�e �a� °o.�% �ecCl �X'_S�S 1?1 �flY3'i�tiVBizl �< � � dis�itiu�:on?acilities inscal_lec� o�or a_f�er 3uiy 1_, 1985. (�) �lo selder cr flu�.wi�.ich conYains �ore than 0.2% lead e�is�s i*� ���ivare �vzter � � C7 dis�bntion faciliiies ins�alled on or Q�er 3uly i, 1900. N��ies S�i✓1C�S��!��IlOi'Oe j�i'OV�G�e�OI��StO=y�YO Ch2�S1V3iv`r!?t�.C�1S�C'i'ib14�IG,�3C�1?EIZS'�T.t�`�Z �ufJ�✓2 COIlC�li_OAS 2i� �Zie�T"�:i7eC�i0'�2 in COT�D1i3IlCti. 7 Cd:`li�f i�l��i�1e iC��C4'�/ll��:i1���ile.�iS Vd311�J��.�SZG� iT±1�P LSr2�lai�vL�JS �}:P�PV3'�:Z'�/�Y�_dis�,'oL�o�rac�1_ii!es �ecm���c7 _ _ b-1 1 1�ptM � r1 rC. _3Il��dY i1:Z LS��CiCi V✓111�V3�1C�c.2�CO?7'i�'��:�G�'�LL"l��'`�7.v�S�eCr0I1�iOCeSS' Sen�ice lsies y ead � Coprer � �tJC � �D�eb � Solde� `Lead � z ead:cree C7 5oi��e�i"�i�Te1_d � " ��er � I recoo ize thz�t 2�is document s�all becone a;oz�-nanent recerc ci tae a��ore�en�tio�ed�blic bl�a�e_5ysten and�hat I a_�.legally :esuo��i'le�or�he validiTy of t��e iniormatien I hzve provided. ,( �°'' � 1��:���,��s � .1 � � � Signature of Licensed?I m'oe: negistration Numbe� � ,��,��fit�y�� � 1 l /�t/1(, � Tyoe oi.Reg:stration Date i reco;nize ihai ii is docurnent snall become a pernaneat recorC oi the afo:ementioned�blic�iV�.te-System and�at I am legaily responsible ior the validity os t�e i.�iornaiion provided. Si�natu:e of Inspector Regis7ation 3�It:nber Ty�z of Registratio� Dztz �i•'hite-Customers Copy - l'ellow-Ciry's Copy . Pin.:-Inspeaors Copy