2017_0602 . f ' i
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I ������4,��' ��`�' ��I�� , upon izspection oi Lhe��va2e yva2ei distribu2ion iaciliti�s located at
Y
'16S ����yy� '>��,��� � �_rvhich is connect�d to the Cit�j of r'flN�ell �v�%ater Syste�, do h�r�by ce�iify
t�4at,io thz best oi my kno��ledge: �
. Ia �Ton- �T/A
. Compliance Cornpliznce
(1) 1`�To dszct conneciion between the public drin1cing wa2er sLpnly an� a poten�ial x< ❑ ❑
source o� coataru��atien exists. Po�enrial sources oi con2am�ation are isolated
ion ihe publ_ic water system by an au gap or an appropzate bac'�:flow prevention
assenbly in accordance wit�'�Corrli-russien regularions.
(2) 1�10 cross-co�necrion be�,vee�iLe pubi_ic drinking v✓zter supply znd a p�vaie wa�ter . � ❑ ❑
systern exists. 4Vhe=z an acfiaI zir gap is not mai.niainer�between the�ublic water
supply and �rivzte water supply, an approved reduced pressur�-zo�e bac?c_�lou�
preveniio� 3sse_nbly is properly i�zstalleel and a seriic� agrez�enti exisrs for
. a�ua1 ;aspection and tesiig by a ce�ifi�d bac�flow preve��ion de��ice tester. .
�'(3) No cor.�ection etists wiich would allou� tLz retuL-n of water uszd io= co�c�e�sing � ❑ ❑
cooling or iadus�al processes bacic to the public water snp�ly.
(4) 1'�o pipe or pipe fi«' g.vich contai.ns nore ihan o.0% leacl e;�s�s in p�va�te v��arer �,< ❑ 0
distribLtion facilities installee7 on or a�er July i, 1985.
(5) I�o selder or flux which contains nore than 0.2% lead e�isis ?n privar� tivzter � ❑ ❑
distri.bLron facilities installed on or ai�er July 1, 1988.
v�ater se��icz s�al1_�ot'oe provided or T�story�eo'ue private water e�is%ibufian_ac;i?iizs ubl �e a'oovz co�ditzons zre dete�?niaed eo be
in conpLaace. •
I ce�-�ify that��e iollorvin�nateri�ls will bz used in t�'�e instala�ion o_F t�e priva'te�vater dis�bu�ion fac'Llities located a2
��'Qo��. ���� y,���_��� and that t'riz inspector vrill valiciat�co�pli�nce duriag ib.e i��spection process:
Seniice 1?nes Lead � Copper ❑ �V� ❑ Other �
Solder ' T ead � Lead ksee ❑ Sol��eni�Neld ❑ Other �
1=ecoo uze that�his docunent shall become a;ozrnanent recosd or i�e arore�nentioned�'ublic ti�later System and ihat I am legall_y
respo� �ble for t�`�e validity of the information I have provided. _
�� 6�-�.,��:,.�' � � a � � �
Signature'of Licensed Fltmber kegistration Numbei
���o��-� ' � � G/2�//�— '
1 yoe oi Registation Date
1 recognize that this document shall become a per.nanent record oi the aioremeationed Public�Nater System znd that I am legally
responsible ior the validity oi the iniomaiion provided. �
Signature of Inspector � Reg?stratioa Nunber
1 ypz of Regist;ation Date
Whitc-Customds Coov ' - v.n„",_r�",•�r�,.,. �� � � n._,. �____�_._.-__..