2016_0814 .
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CI'1'7C 4T C��F�LT�WAT��t UTZLI'FIES �
CLTS',i'OI4�EA SE�YTCE fI�SPEC'�i'J,OI4
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Residentia[ . Commcreial ❑ TNRCC ID�U5'1p04Q �°
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Z �� _ _ � I upo�itispecfion of ths grivate wa[ar distrihtt#ion faailiries located at , � k
� � � which is ca�nected to the C'aty of Cappall Watcr System,do hereby ceztify �
: that,to the best of my knowTedge:
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�o it ce Corn�jiance i:;
(1}� No direct connection befwcen Tbc public dcinkin� water suppIp and a potential � ' L7 ❑ �
source c�f contami.nation exisis. Potentis�sources af cazztnmination are isolated ' ' �
froru th� ublic water stem b an air �'
p sy y �ap or an appropriafe backfIow greuerrtion r
assemb3y in accordanee with Com.mission regulations. . �
(21 No crnss-eonnecfion bstween the gubIic drznking wazar supply aud a priva2e�water �' p p
system exists,��hera an ac4�1 aiar gap is not rnaintained betweea the pu�Iic watsX �
supply and private water snpply, an approved reduced pressnre zone haekf�ow � F'
. �
, pre'vention ass�mbly is proparly instal�ed and a seryice agreemerit nxista for �
annual iuspecfio�snd testing by a cerrified backfla�v prevention device tester: �
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(3) No connacdon e�cisis whicfi would aIIow the rcturn of tivater nsed f�r condensizte �j/ [,� L]
; coa�ug or lndustria}processes back ta tbe public water suppiy, �
(4) Na pipa orpipe fitting wb,ich cordains mare Chan 8.0%lead exists i�przvate watez �• q [� �'
distrihndon facih'�{es insralled an or after.7uIy I,1988. , C
�S) No soider or flux vr#ich con�ains more t�a�0.2°/a lead exis�s in private waier �/ �p • ❑ �
distn'bation facilitits insta]1ed an or a$er July F,I�8$. �
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Water service shall notbe pr�vided or restazed ta ffie private twakes disttihutinn faciliries until the above eondiizons are deter,�rrined zo be
ia campliarice.
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I ccz.ti£y that tbe follo�,�ing materials tvi1I 6e used iu the ic�tallarian of the privace veater dism'buriion faciIities Idoatad at �`
� y� �r'r w c C , _aad that the inspector�svill validate comp}lapce dmittg the inspecrion process; �
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Sorvice Iines Leaci D Copper t_l P'ltC • ❑ p$i.er
Solder Lead Cl 7 ead Frea � Solvent Wel.d L7 Other� �
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T recognize thaCthis docvmenT shaTlliccome a pezmanenf recozd of tha aforementioned Public Water System and that I atn tegally �
responsz�b�r for the validity of the informatzoza I have providad
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SxgttatureafT.ice� sIPI cz� �C�ISII'Hi1va,�NumbeF �"
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s'/�S'. � -��l� _ F;
Type ofl2.cgish�arion Bate �"
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I recog'nize that�this docurnent st�all become a pecmancnt recozd of.the aforementionad�'qblic'Watex System a�nd tha#I am Iegally �'
r�spon�j5�r tfie vulidity of the information 'ded, ,
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SignaLure oX:It�Pec Regist�ation ber °�
G�,S'l�s' .� ��Cj./ � �
Ty�ta ofxagish�ation Daie . j'
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