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2016_0929 � � . , , :,3��Y �r.��J1P�%ri;i�`,:i;�T,���z1��i=�ZI:1-�., n�7�„r..�� T� �(� , .�� �/'�r, 1��-r��� .•: �I � (1,,Uil 1!l:��l'✓�=a r.J!�1�J���LL 1'�v��'L��1��'�j-�l '?.��ir���n�a�� �., �c,;�n,�rs��� � ii I���'�f'1��,'���3�O�iD /JJtt�� f` �;+ I � / � �i���r��r�V`� lill�, � II�`�II _ , ll��Jll L�1S7�G'_30:1 'il=�i_'R� y:l�'3ii, �V3:Gi (�15C=I1J�1Ti02i i=�C111ui,S �OC2�2C� 2C s� � u Q pt� S f�h S /� �, , tiz�I17CI� is ���.eci�d to 1�e �Ci�j o`�oy�ell?7�%ater Syste�-!, cio h�reb/ ceicify �nat,to the best of my l�.�o��le ge: j,� �io�- Ni.� CornpliaLce Co�pl;ance �1� 1�0 a?T�CY CO��eC'i10� �J2h;JE?II i�e �L,ri�1C dP_P��lIl� wate� SL�7;%l� r�i1C� a ,�o'ten�ial Y,< � ❑ sou�ce af conta,�zztien exis�s. �o�er_ral scurces of co�tam.inaticn are isclated iron the public water system'�y an zir ga� or an app��priace bac:�low q�.revention assembly in accordance wit�'�Corrli--lission regLlations. (2) l�o cross-coiznection bec�veen u`�e public 1��-iru'cir.g v�ateT sapply�d a��iva��e�nia�er �" ❑ � syste�exists. bU'nere an acri�al air bap is aot main�.aine�be�een the�v.�l?c water supply and ;�rivate w�tez� supnly, an a�pra�✓ed reduced pressur�-z��� bac?;r'1ou� preven�io- assembly is pro�erly i��sTalled a.�c1 a ser��ice agrez-�enti ex�s�s ior a�ual�spection an.d 2es�-�g by a ce�fied�OackT'1_o�preveLii�r.de��icti c�s�er. (3) No con_neci�on e;'.isis w:iC'� wouid allov/ tLe ietz;.��! oi v�ater used =c_ c�;e�eysi�g � � ❑ cool_��or i��dusu;al p:ocesses bacic to�he public�vater suppiy. (�) �o pipe or�;pe fitting��?�ich contai��s no-e tha� 0.4°'0 le�cl exis�s i�;oi�vate}���a�e� �<� �J L7 dis�ibLtion iacil;�es ins�alled��or arter 3Lly ?, 1988. (5) �?o selder or flu� which con�ai�s �ore *.han 0.2% lead e�isis �n ��iva'r_e bva�er � � ❑ distribut±on facilities inst�lled o� or after�uiy 1, 1908. b`��ieF S�i✓1C� S'�r�:1_no�'oe pre�iiC�.e�C:T�StGTvL}:0`Lle DT7�Id7�tid?��a�iS��i!�L'.`lO�i_'uC1�=�Z5 L��Cll'`�2 ?'OOV��C�C�li�O�S cZ� C2ie-717PCi io be in com�l�ance. �Cw=`�i�1c��7Z fC1101Yll1� �"12�e;Ic�S ti'd?�l�D�'..'.SZd Lz!L�?�1ZlSid�l�.t C�0�?�?aPV3'iZ ti✓3Y�I t?.1SiS1bL�071��C11i1�S SCCa���eT _ 6 �O� S ,v� ��. an��t�aa�"�'ne insyecte_��✓;1?va1_;clat�cor��lia.�.ce dLn-��g`����s�ecrien process: Servicz 11-�es Lead C] Copper � ?VC ❑ �t'�er � Solder ' Lezd � Lead z ree � ' Sci��e�i`�Ie1d � fl2�z_ � , _i:ecoo�,z thzi t��is c�ocLmen�s�all oecome a ae�aneni reccrd c�2�:z arore�entienec�blic vyaiz_5ystem ar.d'��at I a:n 1eg211_y _espon �ble fo:the validity cf��e in_ro=ma�ion I have provided. � ' , ',� �� � �� � . � i � �l � � !1�-�,?��o��„i.d l � I Signatu1 e of�icensed?l� m'oer kegistra�ion�iumbe= ' /���i�'Y��+ �/�/�Uo. Tyoe oi Registration Date i recognize that ihis docLment snall'oecome a pernanert record oi the aforementioned�blic�N�ter System and ihat I am legally responsible ior the validi'ry of the i.n_`omation pro-vided. , � Signature of Ins�ector �Zegist�ztion Nul-nber i ype of�cegis7atic� �aTz �vi.:,.. �-...,,.._._��r....., 1'ellow-Cin%5 Coov ' . Pia1!•I,vcpeaors Copy