Cross-Connection Control Survey Form
State regulations require that all public water systems survey their customers to identify and eliminate Cross-Connections.
Service ID #
Found on your bill
Name
First Name
Last Name
Service Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Rural water is used for: (check all that apply)
Residential
Agricultural
Commercial
Industrial
Seasonal
Please indicate if your residence has any of the following: (check all that apply)
Landscape Irrigation System / In-ground Sprinkler System
Yes
No
Can you add chemicals to the system?
Yes
No
Fire Sprinkler System.
Yes
No
Livestock Water.
Yes
No
Fill Type?
Hose
Automated
Swimming Pool / Hot Tub / Decorative Pond
Yes
No
Water Treatment Equipment (i.e Water Softener)
Yes
No
Is the Backwash / Cleaning Cycle air gapped?
Yes
No
Secondary source of water?
Well or Surface Water
Storage Tank / Cistern
Reclaimed Water
None
Other
If yes, is that secondary source interconnected with the plumbing supplied by the public water supply?
Yes
No
Water powered sump pump (ejector or siphon pump)
Yes
No
Pressure booster pump.
Yes
No
Do you currently have air vacuum breakers or check valves on your outside faucets?
Yes
No
Is or will this meter service be utilized in any of the facilities listed below: (please check all that apply)
Medical / Dental
Hospital / Urgent Care
Mortuary / Morgue
Convalescent Care
Industrial / Commercial
Irrigation System
Educational Institute
Animal Care / Veterinarian
Multiple Dwelling Housing Complex
Place of Public Assembly
Office Building
Car Wash
Restaurant
Shopping Center
Laundry / Dry Cleaning
Nursery, Ranch, or Farm
Do you have a home-based business? (i.e., Daycare, etc.)
Yes
No
Type:
Please describe any other potential cross-connection not covered by the above questions.
Do you currently have an approved backflow prevention device on your water service?
Yes
No
Last inspection date:
-
Month
-
Day
Year
Date
Have you submitted an inspection report for your backflow device?
Yes
No
Submit
Should be Empty: