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1R:e�'s�d���ia3 � �o�rJa��rsa�� � T1a�4��i. �1D"�D�7��fl�3{�
I �� ���I u > upo��zs��ctio;� os T'_�e p�i��a�e �V3iEi d15C7�Jt1210II i8C111i1�S IOC2�ed at
�\'� '���,� '� n �,� Z,Z. , which �s CGPnPC��d to �he Cit�j of Cop�ell ��%arer Systen, do h�r�by ceicify
Lhat,io the best oi my 14�owledge: �
�L� �1on- N/A
Co�npliance Co�pliance
(1) ��To dsect conneciioZ ?�etwee� the publ_ic drin_'.�ing water supnly and a poten�al � ❑ ❑
sou�ce ai coniz�-ninaron exists. ?oiential sources of contarr�arion are isolated
irom ihe publ_ic water system by an 2ir gap or an approp�ate bac'.:flow�revention
assenbly in accordance with Cornl-nissien regLlarions.
(2) I�10 cross-connection berivee�the publ_ic�inking wzier sua�ly zud a p�va�.e v�ia�er . � ❑ ❑
systen exisis. �Yher�an ach?aI air gap is not mzintained Uetween the�ublic v�ater
suPply and private w�ter supPly, an approved reduced pr�sstie-zon� bac?;_�lou�
pfeve�rio� asse�bly is properly iastallec7 and a se�iice agrez�enY e;r�sts for
. a�ua1 inspection and t�sti�g by a c�rtified backr7ow preve�iiov de�;�ice tester.
"(3) 1�To co�nection exisis w�a.ch would allow the retw-n of water used fa co��e�sing � p ❑
coolinQ or indus�al�rocesses bacic to the public tivater sup�ly.
(�) Pdo pipe or pipe fii-�ng�xli.�'ch contains�o:e ihan o.0% lead exssis in p�vate��va'rei � ❑ �
dis�ibLi�on iacilities insialle�on or ai er July 1_, 1988.
(5) h10 solder a flux w�ich coniai.ns �ore than 0.2% lead e�is�s � ��ivace rv2Yer � ❑ ❑
distr�bLtion facilities installed on or afer July l, 19oS.
�ater s��ricz shall aot be provided o�:zstored to 2he private waier d.is'rcibu�ion_aciLazs�ti1_'�e�'oove co�di��ons are deie_��iaed io be
L conpLaace. �
I c���fy�ha2�he iollorving naterials will be nszd in the installa�on of thP�J17Vc��Z bYBi��dis�ibution fac��ties located at
������y�,y��,������r� �,�� and that�e iaspec2or�✓il]va1;c13te comDlia.�ce duriag th�inspecrion process:
Service 1�-�es Lead � Copper ❑ �V� ❑ Other
Solder T ead' � ' Lead�ree ❑ Solveni 1Neld ❑ Othe_r
I recogn_ize that this document shall become a pe_�anent record �f thz aior�rr�en�tioned l�ublic Waiz_Systzm and that I an legally
. =espo� �'ble fo_r�e validity of the infomation i have provided. .
� ° -L � l �t � ,
Signa re of.Licensed P mber kegistration Numbef
� �!Ql�i� � \ �
1 ype oi Registration Date �
1 recognize ihat tius document snall become a permanent record oi the aforementioned Public Wzte_�ystem and ti�at I am legally
responsible ior the validity oi t��?e inioma�ion provided.
Signature of inspectpr � Registrztion 3�lunber
Ty�z of Registi-ation Date
Whitc-Customers Copy � 1'ellow-Ciry's Copy ' , Pink•Iaspeaofs Copy