HomeMy WebLinkAbout1993 12 15 - Example of CertificationExample of Required information for Asbestos -free
Certification for Water Distribution Systems and. Entry Points
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Water System Name: & .k Pznc
System type (circle one): CWS or NTNC
Identification Number (PWS -ID): 331- 4ts 1
Population served:
NO - 3n
Contact person: NA I&W-4001
Contact phone number: -(qMJ SIC, - 2A if
Mailing address: I VUA
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Asbestos -free Certification for the Distribution System and Entry Points.
Pursuant to Rule 17-550.511(4), F.A.C., I certify that there are no asbestos containing pipe, service lines or
other
components in this water system and no asbestos containing minerals in the source of ground water Supply. This
certification constitutes compliance with the sampling requirements of Rule 17-550.551, F.A.C., and no further
asbestos sampling is due by this system during the compliance cycle beginning January 1, 1993 and ending
December 31, 2002. g
Signature of PWS Representative:
(Please Print Name):
Title: Ce r.4 4: e6 Dv a+a✓
Date: l01- 15--5 3
7
Example of Required Information for Certification of
Availability for Unregulated Contaminant Sampling
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Water System Name: Aaek ioJaGe
System type (circle one): CWS or NTNC
Identification Number (PWS -ID):
Population served:
Number of service connections:
I certify that:
_331- q)S,)
3�0
Contact person: -a wr- I ; &-im
Contact phone number: _ �J J7 5- a� Fr V
Mailing address: Qi `
Dl'C
Vero 6euk l~i 3ati G
The above water system has less than 150 service connections or serves less than 350 of the same
persons daily for six months of the year.
The above water system is available for unregulated contaminant sampling.
Signature of PWS Representative:
(Please Print Name):
Title:
Date:
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