2017_0413 �3�I'�l DF��C9PPiLiL`��I.�T�'rt 31i1'll,I;l1F:�
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]k����9�d��Qaa� � �orrar�n�rs�a� 0 'T1 T�i?'� �ID;Fl�57�3i�4�
I �����,U� ���,' ��c,� ,upon inspection oi ihe p�vate tivater distribution facilities ]ocated at
�0� ��„ �T�=M � ,�ic�connecied to ihe Cirij of Cop�ell�riater System, do hLreby ce�cify
that,to the best oi my knowledge: �
L� �Ton- N/A
Complianc� Compliance
(1) No direct connection between the public drin:cing water sup;�ly and a poten�ial � � ❑
source of conianilzarion exists. Poienrial sources of contamination are isolated
from the public water system by an air gap or an appropriate backflow prevention
assembly in accordance with Commission regularions.
(2) No cross-connection bet�,veen ihe public drinking water supply and a privaie waYer . � ❑ ❑
system exists. Where zn actuaI air gap is not maintained beeween the public vrater
supply and private water supply, an approved reduced pressure-zo�z baciy�lou�
prevention assembly is properly uzstalled and a ser�ice agree�ent exists for
. annual inspection and testi�.g by a certiiied backflow preveniion device tester.
"(3) No connecrion exists whicn would allow the retum of water used ro� conc�ensing � ❑ ❑
cooling or indus�ial processes bacic to the public water supply.
(4) No pipe or pipe fiiting wluch con�tains r,�ore than o.0% lead e;�ists in pi�vaie waYei � ❑ ❑
distribnrion faciliries installed on or after July 1, 1985.
(5) I�10 solder or flux which contains more than 0.2% lead exists in private �vaYer � ❑ ❑
distriburion faciliries installed on or aiter July 1, 1958.
�later sen�icz shall not be provided or restored to the priva4e water dis�i'�ution iacilities util ihe above condicions are determined to be
in compliance.
I ce-tify that the following naterials will be used in the installation of thP priva'±e tivater dis�-ibu�ion facilities located at
� � ���and that the inspector will va1_idate compliance during the inspecrion process:
Service lines Lead ❑ Copper ❑ PVC ❑ Other �
Solder Lead � Lead Free 0 Solveni Weld ❑ Other rffi
I recognize that this document shall become a permanent record of the aforementioned Public Water System and that I am legally
respo 'ble for the validity of the information I have provided.
� m �' � �
Signa re of Licensed Pl mber kegistration Number
�a S� �� �'3 / 1 �
Type of Registration Date
I recognize that this document shall become a permanent record oi the aforementioned Public Water System and that I am legally
responsible for the validity of the information provided.
Signature of Inspector Registration Nunber
Typz of Registration Date
LVhite-Customers Coov }'ellow-Ciry's Copy . Pink-lnspcnols Copy