2016_0816 • �
£
CI�'X OT C�pP�T..�WA1'L$T17.'I�I'FIES E
Ci7S'z'OMER SERV�C��NSPEC�'�014
Residential �1" . Commcrcial ❑ I'3�TT2CC ID�057p040
� c
� u r
,G l �
Z - � /�'i/ upott it�specfion of ths priti�ate watar distri6ufiop faailitiss located at ; � �'
� �� 9 /i'7CQ�e wbich i�connecied tn tlie City of Cappell Water System,do hereby ceztify �
: ttxat,to the best of my knowtedge: �
. • �
� ' Tn Nan- NIA �
�om liance Corrt�pjiance ;;
(1) No direct connection betrv.een tt�$publie drinking water supply and a pot�ntiaI � ' p q �
source of contaminatiou exists, Patentis�souroes of evntumination are iso]aced ' ' �
fraxn th� uhlic Water sfem b an aur �
I� s7' y gap or an appropriate backfIow preverrcion r
assembfy in eccnrdanee with Co�m,n�ission regulations, .
• , .. �
{2} No cruss-connection bekween the pubIic drinking water supply aud a pr9vate Yvatez� �' p p
systein esists;1�here an ac4.t�1 au gap is nof maintaiued betweea the�u�Iic water �
;
snpply and private water snpgly, an approved raduced pressare-zoue backflow � �
, pre'ventian assGmbly u properly instalied and a s�rvice agreemenf nxis#s for �
�
annual ittspecfio�and tasting by a oertified back#]ax�prevetttion device tester: �
�=.
(3) PTo connecri�n exisfs whzch would aIlow the rcturn of�vater used£nr condensing �/ p �
s c�o�ing ar indusiria}processes back ta tha publi�water supply, �
{4) 'Na pipe orpipe fitting which cor�tains mare rhan&,0%tead exisfs i�pr#vate watez �• q p �
distri6ndan facilities instaIled an or aftez•7uIy I,IJ88. , �'
• • .. �
(S) No solder or flux v�3aich coptains more than,0,2% lead exis�s in�srivate waier � �[,7 � p �
distn'bufion facilides instaTted aa or after July 1,I988, �
i
\� � ��
�Z
Y'
Water service shall natbe pravidad or restozed to the pdvate twater disttihufinn facilzdes until the above eonditiotts ara deteFu�ined io be
7n colnpliariCE. '
k
I ccr.tify that tbe fo]lo��ing materiaIs�rill be used in the installation of the griva[e v1a#ez dism'buti.on facilities I�cated at
7�� ���,,,Q47� ^and that the inspector tviIl valiciflte�omp}lapce d�ring the inspecrion process;
� . . �x
Service[ines Lead ❑ Copper ❑ p'�� ' [� Q�r,� �
SoZder �.ead q 7.ead Free � Sol.vet�k Weld q Othex Q `
a
�
I recognize thatthis docvme.nt sh�Llbacome a pezmanebtrecozd of tha aforementioned Public Water Sysicm and thatl am IegalIy
respons�a��for th,e validity ofthe informar3on I ha �ded. �
! �
� • 4;
Sigttature of Lice� mbcr Itegis�raiA��.Numb�F �_
�s�,�s � _ f:
Type ofR.cgi5trariou Date � �
f
I recognize that�this doctunent shalI become a pecmancnt recozd of.the aforementioned.pa.bli�Watex Syst�m�nd tbat I am[egally ``
r�sponyu�'SIe for the vAlidity of nc�informakion avzded. ,,
/./ 7� // (�
(O {
Signa[ure qX;tt�pe or Re�istratiou Nuznber `�
��✓Sf',�' .� � _/�- �� � �::
� ;
Ty�te of`_Kegishxtion Date . G-
i;
Whi¢-Customctr�upY YcElow-Cit�'s Capy Piok-tnspeburs G,pY
�