2017_0215 1 f . ♦
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' �CU�'I'�.L�i✓I'�'�������-��C�,�i i�FL�LT���� .
]F��P�a��1�en��.�l �^�' �a��r�n�r�caa� � '�'1�T'�II)#�D�7���1�D
I �`������4� �� �',�I� , upon�zspection oi�n�p�v�2z yva2er dis�ibutio�iaciliti�s ]ocated ai
L� �(� ('b�c�,r•�6�,,,� QT�'v� u , whicl� is c�ruected Yo the �Cit�j of CoN�ell L�Tater Systen, do hereby cer'iify
t'�at,io thz best oi my lti�owledge: "
L-� �Ton- N/A
Compliancz Compliznce
(1) �To ds�ct connec�ion between the public drin�cing water supply and a poten�ial � ❑ ❑
source oi contar,�-�arien exists. �o�enrial sources of contamination are isolated
i�on ihe public water system by an 2ir gap or an appropriate bac'�flow prevention
assenbly in accordance wiu`�Comrnission regulations.
(2) I�10 cross-connection bet�,veen iLe public drinhina v�zter sup�l�znd a p�.vate warzr . � ❑ ❑
syste;n exists. �Vhere an actuaI air bap is not mainiained beYween the�u.b2ic water
supply and pnvate water sup�iy, an approved reduced pressure-zo�e bac?c�lou�
pre��eniio� asse:nbly is properly i�zsTallecl and a seriice agrez�znt e;�sts for
.- a�ua1 �spection and testiig by a ce�izied bac�'low preve�tion device tester. .
"(3) i�o connec��on exists which would allow tb.e retu�-n of vrater used io� co�de�si�g � ❑ ❑
cooling or indus'u�al�rocesses bacic�o the public water supply.
(�) T�o pipe or p;pe fiti�ig�,v�ich contai��s nore tha� 0.0% lead e;�s�s in privaie���a�ei � ❑ �
distribLt�on facilities ins2alled on or af�er July 1, 1985.
(5) I�lo selder or rlux which contai_ns �ore than 0.2% lead e�isis in private water � ❑ ❑
� distribution faciliiies iustalled on or afer Ju1y 1, 1985.
vVater sen�ice shall�ot be provided or rzstor��Yo'Lhe pnvate,�a[�i�15r7tiil11t16I1�ac�l;ries t�til"�z abovz co�di�ons zre dete,_-ni�ed�o be
»conpLance. '
,
I certii��hat��e iollorving nateri�ls will bz nszd in the instala�ion o_F the priva2e water c�is�bu�ion iac��ti.es located at
�S� C6�y,r+��N� p��I�+¢ and that t�iz inspector t�ill va?iclate co�pLiance duriag the i��specrion p,-ocess:
Senilce l��es Lead � Copper ❑ �V� � Other �
Solder � Lead � Lead lrree ❑ Solveni�Neld ❑ 02her �
I:ecognizz chat this docnneni shall become a pz�nanent recorcl o��`ihe a_forenentioned�'ublic tiVater System and iha2 I a�legally
resAo� �ble for the validity of the information I have provided. .
�� ��i��.l�n�� a 9 ° IS @ �
Signature'of Licensed F1-mber kegistration Number
���Q-��� i oC/��� I ( i
lyoe oi Registation Date
i recognize that ti�is document shall become a pernanent record oi the aiorementioned Public yVater System znd that I am legally
responsible ior the validily oi the iniomaiion provided.
Signature Qf Inspector " Registration Number
Ty�e of Registration Datz