2017_0331 _— . . . ...�. . . . -. . •. . _... - . -
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�R�irl��a¢ia9 �. Co�naer�cial C7 1 i �'�C�#057dt��ifl
� }'�'���,►�� �{;��C�' . ,npon i.n��ection of f�t privata water distribution iacili�.es located at
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L U�' ���C�r.,._,_, ,wizich s connec�d to the�Cit�j af Ca��e2l�iater Systen, do heraby cerciFy
t�at,io�e best oi my kaowledge: � � ' '. ' .'
, , ia Non- N/A
• . . ' Co�lianct Co�pIiaace �
(I) No d�-ect conncction betwcea tt�e pub?ic 'dn�.=ciug water sup;�Iy aad a �oten�al � ❑ 0
source c,con�-�i.natioa exists. Po�ental sources of contamination are isoIated
fron�he pubIic water system by aa 2ir gap or aa appropzate bac'.cIIow preveation
asser�iy in accordznce c,rit'�Com�zission regula�ons. '
(Z) No cross-connectioa be't�een�he pLbsc d�-inking water sugply and a p:ivate water . ' � ❑ D
system exiss. Where an actuaT zir aap is not main�ine�betwern the pu6L'c water
_ ... suprly znd private watex supply, an �sproved zeduc�. pressiue-zane.bac�loa�. ._._ . _ ... . . .. . . _ . __. .. . . . _
pre�re*.1i.�'o� 25SembIy is properly instzlled aad a service a�eement cxis� for
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annua�.�spec�on a�,d tes�.g by a c�n�d backx7.ow preven�on devics test�r. . .
=(3} No cornection e:cis� wiiciz�wouId zllorv t�e ret�,of water used ior con.c�ensing � p ❑
coolin�o�indus�ial processes bacl�to the public water s�.*�ply. .
(�) No ai�e or pipe�ttind which contaius nore�lan.8.0%Iead exists in p�va�e wster � ❑ ❑
dis�ibLtion facili�es installed on or aftes Jaly 1, 1988.
(5) No selder or flu;. u]ic1� contains zaore tban 02% Iead�exists in private water � ❑ ❑
• � dist�.butio�faciii�es insalled on oz af��er hziy I, 1988. - . �
v-Vater se�vic,:s�a1l not be provided or restore�to�e private water dis�butian faciL='ties t�ti1�e above conditions are dete�ed to be
m compliaace. . '
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I ce�-�fy�hat�.e followi.ag r,s�terizls wiiI be used ia t�e irsta?la�ou of the private water disazbu�on faciities located at
�y�-' "���,�, � ��.� . • and ihat t�ie insaector crill vz?idata complia�c�duriag the iaspeciion�ocess:
Serrice Iines Lead � Cop�ez � PVC 0 Other �
Solc�er ' � ' Lead �J Lead rree O Solvent Wcld LI O'tb.er � ,
�I:ec o¢niz��at this dacement s�al1 became a p��nanent recard of�e zforsmention�d Public Water System and that I am Iega]Iy �
resDo ble for t�e vaZidity of the informarion i have provided.. • .
° �� '� 1 � � � �
' Signa e'of Licensed?1 ber ' � . Registration NumbeF ' .
��5-f�s � ' � � 3/ 3� 1 �-� '
Tyoe ai Regis'�ation , Date . .
3 rrcognize`�aat this document shall become a pe.:zianent record of the aioremen�oned RbIic�Izter Syst�m and that I am legally
responsible io;J�e validity of the information grovided. � • .
S'sdnature Qf Inspectar � ' • gegis�ration Nur,�ber, .
� Type of Regis�atioz ' . Datc ' '
'�'^ii:c-�c;i�.--�:Cm_�; ' ydlcw- i Co � Piak-
. ��Y� 9)' Insyeno'.Coa%