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2016_1010 � , `� , , , �'31,1 �F ��JF��,+,ri;l, ?;;�:�i����1��i��LI;1?�� � '�vilT!�1/�ii S�I���J11�i,�1�jJ�i'��1�'�i1 �=�i '�3��i�r��nra�] ��i, �'��nn��rs�s� � it���u�I���U��OO�;�D �� � , �;=�(;�U,� ��'�: � ��I „ ;, ; � � �, � , �;� �_ l� ;�� �, L I cJ�( �on�s��c��on �_ ���p�v�te va2er distri'u2ion i�c:li�_�s loczted a� ��3 /�d�G4� sd///�. ,S _ _, d�/17?Ci3'?S �6ILP�i�d t0 i7: �l�f OZ�O��el� Zi�/2tz7 S�S�eny C1C tili.Z�by cer'iify .- 3 �zar,to the best oi my l:.no��ledge: �,-� �ion- N/A Co��liGnCz Co;�-�pl�a�ce (1) 1�o d�-�cY conseci;on between �he public en:�_?,ing W2ieY SL"p01� 2.11� a �oi�.n�al � � ❑ sou�ce ci ceIliciill172i1CIl exis�s. �o�ert-�ul sources oi contan1-�aticn are isolated uon ihe public wa�er syste�by an air ga� or an appPopsiace bac'nz�o��✓g�rev�ntion assenbly L-�accordance wit�'�Corr��-�ssien regula�ions. (2) 1�10 cross-coznection bec�vee�u`?e pubi_ic �i��;�ng v✓ater suppl��id a��va��e v��a�er ���. CJ ❑ systern exists. �Uhe=z zn actLaI air bzp is aot:maintained be�ween the�u.bl�c water supply and ;�r�vate v✓ater suprly, an aapi�✓ed reduc�d p:zssure-z��e bac;:�7ou� pr;,veniion asse�bl_y is �roperly i��s�allee� a.nd z se�iic� a�ree�e�t ex�sts ior asual_ins�ection��d r�sr�g by a ce��?�d T�avk?1ow preveziio�de��icv Y�s�er. (3) No con�ectien e-sists w�c'� �uould alio�i t�e re21L'Ti OT V�ai�F LS2� =0I c�rde�s�c � ❑ ❑ cool�g or in?usu�al p_ocesses bacic to t;�e Yublic water sL��ly. �'�� 1�10�ipe or�ipe Ilitl2?��vich co�iau�s-zore i�21 °o.�°�o leu� �X?SLS LI�S.Y3LP�n/aC2a ,� ,� Q disYribui±o�zacilities i�:si�lled��or after 3uly 1, 1988. (5) �10 selder or ilu� w.'eich contains nore Yh�n 0.2% ]ead ex?sts in p�iva�rP dvaYer � � ❑ dist�b�tio�racili�ies izst�lled on or af�er 3u1_y i, 1908. +1�Ia�er s�rvice sh�L1 no�oe?rev�ded or-estc_d�Yo`ue priva2�:w�iea�is'�buYic a_aci?:`es Lt�l `�z�'oove co�dit_ons are dete:-ninec io be in com_pliance. �rr!ilf�f i17�T�i72�C��CWLZo �=t7c2eileeS Vdtl� '02'1S2d L'1='le 1IISt2�13�705.0�`L}1P ,a�V�1':Z ti✓���=C15i?1b11i�..riII��C1_�1��5 lOCs2r��c� 7.r3 /�O���WJ�`���_ t'�zt�'ciz iss�ec2c.�a✓;i�vai_ic�at�co��.��anc� dur�a`�e i�specrien�rccess: Ser�iicz 1;,-�es �ead L� Coppe� �'1 rV� ❑ O`�her � Sol�er i ead � I,ead.�r�e � Solt�e:�i'�Te?c � t)2�er '� ' ?recoo_izr that�his docL:-�en:shall oeco�e a pe��nent record oi thz afo�vrrenrie�zd�blic�iNu�z-5ys'tem and�.���i a._�lega'ly _espon� ble fo_rhe valicily o�2�'�e ui.for�naticn I have provided. 1 , i � �r1 i�c����I���� , � �f ,' � � Signature of Licensed Pl rnb'er kegis�a�ion Nu�nbe: ' ' ����.�=�-�`� ' �(T�� �-� / � �_ � 1 y,ue oi Reg:station Date i recognize ihat this document shall become a pernanent record oi the aforemeniioned�ubi.ic�iVate:System�nd�at I ar_:lega?ly responsible ior�h_e vai_idi'ry o�the�niomation provided. Si�nature of inspector Regis��aiion tti'umber T;�z of?�egis�;a��c� D�tz �h'hhe-Customers Copy � 1'ellow-Ciry's Ca9y , Pin.;-Iaspenofs Copy