2016_0816 � �
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C[TS�'OMER SERVICE fI�SPEC�'kOI'k
Residentia[ �" . Commcrcial ❑ 7"P2TtCC ZD�#U5'1p04D '�
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Z / ' � a'��e / � upott inspecfivn of t3is griti�ate wa[er distzihution faailities idcated at . �
� �� v � wbzckz is conneci�d to the City of Cappall Water 5ystem,do hereby certify �
that,to the best oP my knowledge:
� ' In No»- NtA �
�ompliancs Com�liance �;
(I}� No direct cons�ection betwesn The public drznki�zg water suppIy and a patan6al � ' L7 I] �"
souree of contaminatian exisis. PotenaaX sources af eozct�mivation are isolated ' ' �
fzam th�public water systern by an air gap or an appropriate i�acktIow pzevention
assembfy in accordance with Coznmission regvlatians. ,
(2) Nn crnss-aonnectian bskwean the public drinking u�azar supply aud a p�avaTe watec �' D p
system exists;lYiYere an ac4.ut1 au gap is nof,maintaiued batween the pubIic watet
supply and przvate water snppty, an approved reduced pressure zone back�ow � �
, pre'vention assembly is proparly instalied and a seryic� agreemenf cxis#s for �
annual ittspecfioz�and#asting by a oerYifed backflatv prevenkion device tester:
(3) 2�To connecrion exisis which would aII4w the rctBrn of tivater ased£or condensin� �' p �
s coo�g or tndus�ial processes back to tha pnbli¢water'supply, �
(4) Na pipe orpipe fitting vrhich condains mare Chan 8,0%lead exssis i�przvate watez �• q p �
distri6udan facih'iies instttlled an ar af�ez]'uIy I,1988. ,
�5) No soider or fiux vz�ich coufains more thau 4.2°/a lead exists in privatg water � �[p � p �
distn'bntronfacil•ttiesinsta7ledanora#terJuly 1,I}88, ��'
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�ater service sha21 natbe prpvided or restored to tbe private wat�r distribut3nn facilzdes until the above eonditions are daterAaned io be �
ia cam�ili,arica.
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I c�rtify thaE the fo�lo��ing tnateriaIs EviII be used in tha installation of the gzivace vra#ez dism'bui�on facitities Ibe�ted at
�.s y ��n�s'e3r/' and that tha inspectar will validute comp}Iaace d�nittg the znspecrirnr process; �
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Seivica[ines Leact L] Copper ❑ PVC ' C� Qtkier �
Solder Lead L7 X..ead�ree � Solveht Weld C7 Othaz ❑
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I recognize that this doctunent shail liecoma a pezxmanent recoxr7 of the aforemenfionad Publi�Water Spsiczn and that I am Iegally
respons�l�for the validity ofth�information T provided.
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, 8xgnatureafLice � m ar Ztegisaaia��.Numbef k;
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T recognize ihat•this doetunent shalI beeome a pecmanent reeord of.the aforemeationed�nb.li�1�V�atex System�nd Tl�at I am fegal]y "
r�spon�,Ie for e validity af the infoima[ion provided. ;'
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Signa[ure qS"Iz�vec Reg�st�atio�t Nttmber � N
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Ty�o oFKegishxtion �
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W1u¢-Custom�ts CUpy YtUoW•Cit�s Cnpy Pidk•lutPtqw't CaPY
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