717 Rock Springs }� �
�'�T�1 rJ�';���PP���1,,'L�i;��'7'i:l??J`T'Il�I d 1�:� .
' �CU�'I'�C�iil��'�����`/����� �i T�P�tL"TI��i� '
IE����i�r����aa� � ���rn��:rsaa� � Tt��T'� i�; r4�9�����1�
I ��g,� , up�n izspection �?i.�e p�ti��tz �,vater dis��ution iacili�ies loczted at
""� �'� Q 6e � � , which is connecsed to 2he �irij of�op�ell zi�lztz,Systen, do h�reb/ ceicify
��_��_�
tna?, io the best oi ny lc��o�ledge:
�� Non- N/A
Co.iipliance Co�pliance
(1) �To d�rect CORIleC'i10i7 TJeC4JePIl the publ_ic drinscing water su�ply and a poten�ial � ❑ O
source cf contz���atie� exis�s. Potent-ial sources oi co�tamiaaticn are isolated
fron ihe public water system by an zir gap or an appropriate bac'nflow prevention
assen'o1y in accordance�vit�'�Cornl-Zissien regulations.
(2) r10 c_oss-connecTion be�vee�the pubi_ic cLinking v�aTer suaply znd a p�vaie wz�er � ❑ ❑
system exists. WV'ne;z zn actuaI aL bap is not�naintained between the public v�at�r
suPp1_y and l�nvzte water su�tly, an approved reduced presslzre-zo�e bac?clow
pre�✓entio� �.ssembly i� properly i�zstallec7 aad a se�iice agree�enY exists for
, a�ua1 �s�ection a�d testiig by a c�Tiizied back*1ow preveation device tester.
(3) Ko cor.neci�on exisis wic�would alloui tbe ;etuL� oi wat�r uszd�o� co�e�en.sing � ❑ ❑
cocling or i,�dusuial p_ocesses back io the public�iater supply.
(�) P�o pipe os pipe rl�`�i�-�g ��ich contai��s�ore ihan o.0% lead e;sisis in p�va�te���acer ,� ❑ ❑
dis�bntion iaciliries inscalled on or a�er 3uly ?, 1988.
(5) T10 selder or flux w�ch coniains �ore than 0.2% lead exisis �n p�ivafe �vatei � ❑ ❑
dish�.bu�±on facili�ies i�est�lled on or a.fter Juiy 1, 19So.
b�Tater se��ic,;shaL�o�t tie provided o_=zsto_ed to�he privatz wz.ter elis'�ibunan facii��zs Ln2i1"�e a'oove co�dii�ons are deiesniaed io be
;n cormpLaace.
I c��-tify'�at dze iollowL�o�aterizls vrill�e�?sed in the installa7on of t�e pritia'+e tivater dis�ibu�o�iacisties 3ocated at
and�hat the inspector w11 val;�ie co�plia.nce duriag'`ue i�sz�ecrion process;
Service 1�es Lead � Copper ❑ PV� ❑ Other �
' So1�er Lead � L,ead lrrze ❑ ' Sol��eni Weld ❑ Other ' '
I recoo izz u'�z�t�his docunen�shall oecone a permanent record of t�z azoreinentioned i�ublic V�Iaizr System and i��at I a�legally
resAon 'b1_e io_.the validity oi�he irLfo?nztion Z have provided. .
��,..-� .,,,�� � � � � �i � � ,
Signature of Licensed PI mber_ ' icegistration Number '
� , �
�/�.a�-��r � � .
1 yoe oi Registration Date
i recognize ihat iius document shall become a pernanent record oi the aforenentioned Public bVater aystem znd that I am legally
responsible ior the validity oi t�ie iniornz�ion�rovided.
Si�natu�e of Znspector . Registration Nunber ,
1 y�e of Regis«ation Date
� .�ti..- '"-----'-"--_ � v.u,.",_t'�r.,��r,,.,., Pink•I❑soenofs CovY