2024 CROSS CONNECTION SURVEY

2024 CROSS CONNECTION SURVEY

The Cross Connection is a survey that is required for the Illinois EPA. This survey must be completed prior to February 1, 2024 to prevent further action from the Virden Water Department.
Date completed*

MonthDayYear
Date
ACCOUNT #
you can find this number on the bottom left of your water stub. Ex. 0050055500
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address 1

Street Address Line 2

CityState / Province

Postal / Zip Code
Please choose YES or No for the following questions:
In-ground lawn irrigation system*

YESNO
In-ground swimming pool*

YESNO
Private fire protection & lines*

YESNO
Boiler heat system*

YESNO
Water cooled HVAC systems*

YESNO
Food and/or chemical processing equipment*

YESNO
Laboratory facility (lab/chemical facility not restroom*

YESNO
Private wells systems hooked to existing water system*

YESNO
Private wells NOT hooked to water system*

YESNO
Any backflow perventers installed at your property:*

YESNO
If yes has it been tested

YESNO
Date last tested

MonthDayYear
Date
Service line

The Illinois EPA now requires the Water Dept. to inventory which material our customers service line are made of:
Please indicate to the best of your ability what material your service line is
When the survey is complete click submit at the bottom of the page. If you have any questions about how to complete the survey or submit it feel free to call the Virden Water Office at 217-965-3711.
Should be Empty:

Service line