Survey Form

2023 West Dundee Cross-Connection Control Backflow Survey Form

This survey, mandated by the State of Illinois, will help identify those potable water systems users or customers that require the installation of a Backflow Prevention Device and will prevent the contamination or pollution of the Village water resources.

Please complete the form below to the best of your ability or consult a licensed plumber for assistance.

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PROPERTY ADDRESS

Property Owner*

Physical Address*

City, State Zipcode

Phone

EMail

MAILING ADDRESS

(If different from Property Address)

Name

Mailing Address

City, State Zipcode

Contact Name

DO YOU HAVE ANY OF THE FOLLOWING ITEMS AT YOUR PROPERTY?

Fire Sprinkler System

Yes

No

Lawn Irrigation System

Yes

No

Commercial Ice Maker

Yes

No

Carbonated Beverage Machine

Yes

No

Water Tank Truck Filling Station

Yes

No

Industrial/Manufacturing

Yes

No

Hose Aspirator for Spraying Chemicals

Yes

No

Large, Commercial Boiler (not a water heater)

Yes

No

Does your business use chemicals, such as a medical facility or beauty salon?

Yes

No

Do you have any equipment hooked directly to your water lines?

Yes

No

Are there any backflow assemblies present at your property?

Yes

No

Cooling Tower

Yes

No

X-Ray Machine

Yes

No

Swimming Pool

Yes

No

Farm Equipment

Yes

No

Medical Equipment

Yes

No

Photo Lab

Yes

No

If so, how many?

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