2017_0416 �
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Residentia[ � . Commerc`t•al ❑ TNRCC 7D f/057S304D
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I ' upon iz�specfion o�the grn�aie wa[er distri6Ufiou facifities located at , ; �`
� wb3ckt is connected to the C;ry of Cagpell YTatcr Sys#em,do hercby certify � �
: that,to the bcst of my owTedge; �
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�om liance Corr�liance �
(1} No dizect conneetiou bettiveen ih$public drinking water supply and a pot�ntial f�° ' p ❑
source of contamivatioa exists. PotentiaX souraes af cozitumination are•isolate� " ' �
frozn the public water sysfecn by an aiz�ap or an approptiate hackflow pxevention
assemb3y in accordance with Commission regvlaaons. .
(Z} No cross-conneclion behveen the pu6Iic drinking wazar suppiy aud a prlvaie water � p ❑
system��xists,�1�Jhera an ac4uil aiugap is notuu�+intained between the pu'bIic water r
supply and private water snpply, an apprflved reduced pressare-r.que buok�]ow � i;
, prei*entioit assambly is proparfy instalied and a service agreement nxists for �
annual iuspecdonand testin�by a certi#iad backfl�w pzevention device tester: �
(3) No conxtecrion exists whicfi would aIIow the rctum of�vater used foz condens�ng � p n i
s coaI'mg or indusfr�a}procesaes back tv the pnblie water"supply, �
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{4) 'Na pipe orpipe fiitz�g ivhich corrtains more[han 8,0%lead exisfs iu private watez �- ❑ p �
distri6utian facifities installed att or aftez 7uly I,I988. , �
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{S) No solder or flux vfhich eonfains more thau 4.2°/a lead exists in private water •p • ❑ ,,
disin"bukion facilides fnstalled aa or after 7uiy 1,1988, �
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Watec servioe sha11 notbe pravidad ar restored tfl ft3e private vrater distrihution fact7iities until the above eanditions ate d�teiminsd to be
in cam�iliattce.
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I ccrtify that the follo��ing tnaterials 1Evill 6e used iu the installation�f the pzivace wa#ez dism'but�ou faciliries]6cated at �
7,� CiCd/,/I C 4/ ! aud that the inspector will validute comp�lance d�g the znspectivn process; �
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Service liaes Leaci � Copper CI PVC " ❑ Qtlier� �
Solder x.ead q X,ead Frea � Solvenk Weld q p��z` p
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T Xecognize ehat this doceuneni shaIlliecome a pennaneuf reeozd of tlte aforementionad Pubfit Watef System and tbat I am Iegal)y '
respons���f the validity of the informahan T have provided. �
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Sxgnalure of Lic� d ar �.tegisaaii��.NumbeF
(�t�f�� y�-%�—/� . �
Type ofRegisfrafion Date ' �
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Ixecognize thatthis d�ctunent shalI beeome a pecmancnt recozd af.the aforementionad Publi�Watex System�nd thai I am IegalIy �
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respon�£jbie for tfie vuiidity af the infocma6on ovz d, �
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Signa e i r Regisaation_��f/� �
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TyQa ofxegistration Datc . i:
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