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ci�x ar ca�g�r.x�w�.r��.u�x�z�ri�s
CiISTOMER�ER'VXC��I�fSPEC�'ka14 I�
Resident�aI � Commcrcial ❑ T2�'RCC ID�U5'1b04D �
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I � / _ c [,'/ upon inspec4inn of the private water distribation faoilities located at : i ��
' �s i' wbackz is conneci�d ta the City of Cappel!Wafer Sys#em,do herebp certify '
: that,to the bast of my kno edge: �
• rn Non- NlA �
C.'om lia.nce Corrt�liance �
(I)• No direct connectiun betwcen YUe pAblic drintcing wa#er supply and a potentiaT � ' �} l] F
source flf contamination exists. Potenta�l souraes af oont�minatibn axe�isolated ' ' �
frozn thc public water system by an air�ap or an appropriate backflow pzeverstian r
assemb3y in accordan�e with Commission regulations. . �
(2� No crnss-connection between the pubIic drinkirag wazer suppZy arzd a pravate water � CI p
system�exists, 1�hero an actnal air gap is notmaintained betweca the�u'bIic watex , ;�
snpply and g.�vate svater sapply, an approved rednced gressure-zqne bnekf�oK� I:
, preventioit asscmbly u properly instalied and a servic� agreemenf exists for �
annual isaspeotiox�artd testiu�by a certified backflnvr prevenk[on device tester: �'
(3) No connecd�n exisis whicl�wauld aliow the rctum af�vater ased foz condeusiug (� p �
; coo�ing or Indusiria}processes baak to tha publia tis*ater supply, `s
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(4) Na pipe aspipe�itCing�hich eorttains mare rhan 8,0%lead exists in private watez �• �j p �
distrihution facilifies insiaIled an or aftez•7uly I,19$8. , �
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(S) No solder or flux w3aich aonfains mare thau 4.2% lead e�sEs in�srivate water � �p • p �
distn'b�i�on faciltties insta7led on or a#ter 7uly F,I988. �
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Water saxvice shall natbe pravided or restored to tbe private vvat�r disttihuiion facilides until the above eanf3.itions axe detetznined to be ;
iL compliattca.
I cmrtify tha E tbe fD11o��iz�g terials�rill he used in tha insEallatian of the.privace watez dism`butzon faciliries 16cated at E
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-- 11�� �/Gi�� ^and that tha inspector tviIl valit3ute compllaace durmg the zrtspectivn process:
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Servica lines Lead D Copper �l p'VC - [� pilier ,� �
Solder T.ead q X..ead Prea � Solvent Weld CJ Othar ' (� �
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I recognize thaCthis docamettt sha111iecome a pez�manent recoz�of the af�rementioned Publi�Water System and that 7 am tegally
responsz�b��for the vaIiclity of th�inforruation I have provided. �
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Sxgnatura o Lice" m ar �Zegistraixv�.Numb�F '�
Type ofR`eg�'ts�'ah'ns Date � /�/� ^` � �
X recoguize that.tl�is document shalI becorne a permanent record of.tlte aforc�mentioned.public Water System�nd that T am legalI�
r�spon�SIe for the validity of thc infocma' ovided,
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Signa[ure p�:It��ec4 Re�is�atinn Number �
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Ty�ss oFrceg�s�at3on Datc .
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PY YtIIoW•Cit�s Capy Pirilc-lurPcqo�s Cnpy 4
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