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
In-ground swimming pool
Private fire protection & lines
Boiler heat system
Water cooled HVAC systems
Food and/or chemical processing equipment
Laboratory facility (lab/chemical facility not restroom
Private wells systems hooked to existing water system
Private wells NOT hooked to water system
Any backflow perventers installed at your property:
If yes has it been tested
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