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CiJSTOMER SERVXC��NSPEC'�T'k014 �
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IZesidentiaf � Gommcrciat C7 TNY2CC ID�fl57b04D �
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I � _ _C / / ugon tnspectican o�tha private water distributiou faciiities located at : i �'
' y �n ��^ ' ` wkuatz is cat�necicd to the City otCappeII Water System,do hereby ceztify '
: that,to the bast of my knnwTedge:
• • Tn Nott- 1,tlA
Com liance Co�Itancc �Q
(J.)• No direct crnu�ecfivn betrv.een the public drznkiag water supplp and a potaniaal �✓ ' p �) �
source of cantanvuation exists. Potantis.l sovrces of eoz�tnminatiart are•iso]ated ' '
frozn the public water systern by au air�a.p or an appropriate backfIow greventian
assemb3y�accordanee with Comnrission regulatians. ,
{Z} No cxoss-connectian bekwean the pubIic drin]cing watar supp�y aud a private water �'' ►� p
System�e:cists,Nhera an acduil azr gap is notmaintained betweca the pubIic water
snpply and pzivate water supply, an approved raduuced pressnrc zone hackf�ow �
, pre'ventiou asscmbly is proparly instalied and a s�rvic� agreement nxists for {
annnal inspectionand testing by a eertifiad bacic#]aw prevention device tester:
(3) 2�to connection exists tyhich wauld aIlow the reLurn of water used foz condensiu�, � p 1] r
i cooIing or lndusiria}processes back to tha publie water"supply,
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(4) Na pipe orpipe fittzng�Aich oorrtains mare than 8,0%lead exisis i�private watez �• q (� :
dis�ibntion facilities instaIled att or aftez.7ufy I,1988. ,
t�) No solder or flux �v3�ich contains more than 4.2°/v lead e�sts in�rivatc watar � •Q � ❑
distn'bution facilities installed oa or after 7uly I,I988. �
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Ys�ater servioe shall natbe pravidad or restored to the private wat�r distxil�utinn facilities until the alaove conditions ara detenminsd to be
iL com�il%atzce. :
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I ccrtify tha t the folla�-iz►g u�aterials�iII be used in the instalIarion of the pzivaee watez distn'bution facilides]c�cated ai
and that the inspector tvill validnte compk{ance deu-ing the znspecrian process;
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Servica[ines Lstd 17 Copper 4 PVC ' ❑ dtli.cr
Solder Lead L7 X..ead�rea � Solvant Weld D Othcr �
I recrognize thet this docvmant sha11 tia e a pezmanent record of tlae aforementioned Publi.a Water System and that I am Iegally �
respons��for the validity of the" rmatzon T have provided. ;
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Si.gnaturcr of Lice� (umbex Zt�isffaiiu�Numb�F
Cvs.o.S - r.?- �s--/� . �
Type ofRcgisfiafion Date
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Z recoguize ihat•this d�curnent shall beoorne a pemiancut record of.the aforementioned k'qblio W atez SysCem�nd fhat I am IegalIy �
cesponycijble for tha validity of tFte infarmation pravided. �
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Signature a�=�t�vect Registration Nuznber �
�____C`�„S�.S ' ����" �� �
Ty�sc oFxegish�ation � Daie .
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Whi¢-Cuttam�s CUPY YcIfOW•Cit�'s Capy Pi�skk-IntAulofx CeAY �
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