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CERTIFICATION TO CAYUGA COUNTY HEALTH DEPARTMENT COMPLETION OF A WATER SUPPLY IMPROVEMENT Applicant: Water District of Area Served: Town, City, or Village Design Engineer: Project Description: Date of Plan Approval: Date of Start of Construction: FLUSHING Date of Completion of Construction: Date of Flushing: PRESSURE/LEAKAGE TEST Start Date/Time/ Pressure Finish Date/Time/Pressure Actual Leakage Allowable leakage DISINFECTION Start Date/Time/Residual Finish Date/Time/Residual Final Flushing Date/Time/Residual BACTERIOLOGICAL TESTs Laboratory Results are attached CERTIFICATION I, certify that the above water supply improvement was completed in conformance with the approved plans and specifications. The information entered above was the result of actual tests conducted under my direct supervision. (Signature) (Date