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CI'X'1'QI�COPF�LY.,WAT�12 U'�ILITIES
CZISTOMER SER'VZC��I�ISPEC�`Z014
Residential � � Commercia.l i� 'I?`TRCC ID�057p04D �
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I %G L upon inspeotinn a�the private water distri6afiou flacilities located ai : i �
' /1��'l l wbickz is ccrnnecied to the City of Cappall Water System,do hereby cez#ify '
: tha to the bast of m owled e: �
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� � Tn Non- NtA �
Com liancs Compliancc �";
(I)• No 3irect c�nnecrian betrueen Yhe public drznkiag water supyly and a potential � ' p ❑
source of cantamination exisrs. Pat�ntisl sources of cozitnminstion sue�iso]ated ' ' �
frozn the public water system by an,aiz gap or an appropriate backtlow gxeverrtion �
assem63y in accordan�e with Con�mission regulations. `
(2� No crnss-connection betweea the pubIic drinking wazer supply and a private�vater � CI p a
system�e:cists,SYhero an aahuil air gap is notmaintained batweea the�ubIic wate�
sr�pply and gzavate water snpply, an approved rac3uceci gtessure-zon� baekt�o�� � '"
, �
, pre'vention assembly is proparly imstalied and a service agreement cxisis for
annual iraspeatiox�snd testing by a certi#iad backflativ prevenkion flevice tester:
(3) No cnnxtecrion sxists ulhicfi wou]d allpw thc rctum of water used foz cpttdensi�n� � p L7
i aoormg ar industria}processes back to tha publia water supply,
{4) Na pipa arpipe fitting vyhich corttains more thau 8,0%lead exisis iu private watez �• q ❑ ��,�
distrihutian£acilitics iastaIled an or after.7uIy I,I9$8. . G
• , . �
tS) No soldsr or flux w3aich contains more thaza.4.2% lead exists in�srivate watar � .Q , p �
distn"bution facil�ties instxlled an or af�er 7uly 1,i988. �
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Water sarvice shall natbe providad or restozed to tbe private vvatas disttihu[ion facilz4es unbl the above eanf}.iiaotts are detezzrrined to be }�
in com,gliarice. ,
a
I ceztify tha t tbe follau�iz�g materials�ri1l be used in tha ics�tallation of the grzvace watez dism'buri.on faciiities 16cated at E
s a
3 � � s aad that the inspector v,�iil validute�omp}lapce durntg the xnspectivn process: ;
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Service lines Lead D Copper �l PVC ' ❑ Otlicr �
Solder T..ead q X,ead�rea � Solvent Weld q Othet (�
T recrognize tbaC this doctunent shaT]tiecoma a pezmanent recazt3 of the aforementioned Public Water System and that 7 am tegally a
responsih�r for tb,e vaIidity of th�inf'ormaLion T have provided.
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Sxgnatura of Lice� �Pf cz� �egistraii�,..Numb�F �
G'JS.I�3' - � l-�2 ^/7 . �
Type of'Itegistrafion � Date �
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I recogitize that this doctunent shall become a pennanent record af.the aforcmentzoned Fublic W atez System�ud that I am IegalI� `c
respon5ijble for the validity af the informatio avided, t
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St atuFe pS,�t�pec � �
� Re�istratiora Nuznber
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Ty�te ofKegiskxt�ort Date _ r
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