2020 Cross-Connection Survey
This mandatory survey form needs completed per Illinois EPA regulations prior to October 10, 2020 to prevent further action from the Commission.
Account #:
*
Do not include the ending dash and number
Customer Name:
*
Service Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number Listed on Mailing Needs Changed:
*
Yes (then provide new phone # on next line)
No
Primary Phone Number:
-
Area Code
Phone Number
Please check Yes or No on the following items:
In-Ground Lawn Irrigation System?
*
Yes
No
In-Ground Swimming Pool?
*
Yes
No
Private Fire Protection & Lines?
*
Yes
No
Boiler Heat System?
*
Yes
No
Water Cooled HAVC System?
*
Yes
No
Food and/or Chemical Processing Equipment?
*
Yes
No
Laboratory Facility (Lab/Chemical Facility Not A Restroom)?
*
Yes
No
Private Well System Plumbed to Existing Commission Water?
*
Yes
No
Private Well System Separately Plumbed From Commission Water?
*
Yes
No
Service Line Material
The IL EPA now requires water suppliers to inventory which material customer owned service lines are made of. Please indicate to the best of your ability what type of material your water service line is that is going from your water meter to the house:
Please indicate to the best of your ability what type of material your water service line is that is going from your water meter to the house:
*
Copper (without lead solder)
Copper (with lead solder)
Copper (with unknown solder)
Plastic
Unknown but not lead
Unknown
Lead (usually before 1950)
Galvanized (usually between 1950 and 1970)
Other
Submit
Should be Empty: