2017 Cross Connection Survey


Customer Information
Resident Name / Company Name:
Address:
Contact Person:
Title:
Property Owner (if different than above):
Street Address:
City: State: Zip Code: Phone:
E-Mail Address
What type of business are you in? (Please be specific, i.e. dry cleaner, shoe store, etc.)
What is your principle use of water?


how many combined (domestic/fire) services:
Water Use Information
Do you use water in any manufacturing/industrial or commercial process?
If yes, please specify:
Do you use any hazardous or toxic material or chemical in any kind of process?
If so, what?
Do any hot water boilers, steam boilers, instantaneous heat exchange water heaters or steam generating facilities exist on the premises?
Is there a fire sprinkling system on the property?
Does your fire sprinkling system have outside fire hose connections?
Does your fire sprinkling system use chemical additives?
Is there a fixed lawn sprinkling system on the property?
Are there any auxiliary water supplies on the premises?
Is there a booster pump attached to any portion of the plumbing system?
Are there any buildings taller than 2 stories on the premises with water service?
Do you have any water-cooled equipment on the premises?
Are there any cooling towers or water storage reservoirs on the premises?
Are there any solar heating systems on the premises?
Is there any photo processing or printing equipment on the premises?
Do you have any potentially contaminated or sewer connected equipment on the premises such as aspirators, cuspidors, autoclaves, specimen tanks, sterilizers ,laboratory, or mortuary/autopsy equipment?
Do you have any laundry or dry cleaning services on the premises?
Do you have more than one service line providing water to your building?
If yes,
how many domestic water services:
how many fire services:
how many combined (domestic/fire) services:
Do you have a backflow preventer installed on the service line/lines providing water to the premises?

Name: Title:
Date:


By Clicking Submit I hereby certify that, to the best of my knowledge, all of the preceding information is accurate and true.