Cross Connection Questionnaire

1. Is your water service location a(n): (required)

2. Renters, please note the name and address of the owner. Owners, note the name and address of your renters.

3. Do you live within the "Flood Plain"? (required)

Yes

No

I don't know

4. Does your property flood? (required)

Yes

No

I don't know

5. How often has your property flooded? (required)

Seldom

Often

Never

I don't know

6. Do you use oil heat? (required)

Yes

No

7. Do you store petroleum products (gas/oil) on your property? (required)

Yes

No

8. Do you have an approved tank or containment? (required)

Yes

No

I don't know

If so, how many gallons?

Is the tank above or below ground?

Above

Below

9. Do you use herbicides for vegetation control? (required)

Yes

No

10. Do you use fertilizer on your lawn? (required)

Yes

No

11. Do you have any of the following? (required)

12. Do you use chemicals that attach to a garden hose? Such as: (required)

Antifreeze Flush Kits

Insecticide/Fertilizer Sprayers

Dark Room Equipment/Photo Lab

None of the above

13. Do you or anyone in your home use a portable dialysis machine? (required)

Yes

No

14. Do you have a bathtub that fills from the bottom; or does not have an overflow drain and is not air gapped? (required)

Yes

No

I don't know

15. Do you have a water softener or any other type of treatment system connected to the drinking water supply? (required)

Yes

No

I don't know

16. Do you have an auxiliary water supply on your premises? (required)

Yes

No

I don't know

17. Do you recieve irrigation water from another source? (required)

Yes

No

18. Do you have livestock (i.e. horses, cows, etc.)? (required)

Yes

No

19. Does a creek, river, or spring run through your propert? (required)

Yes

No

20 .Do you have a backflow device (preventer) on your property at this time? (required)

Yes

No

I don't know

21. Do you have a booster pump? (required)

Yes

No

I don't know

22. Do you have any situation you are aware of that could create a cross connection? (required)

Yes

No

If yes, please explain:

23. Do you have water fixtures three stories (about 35 feet) above your meter? (required)

Yes

No

24. Do you consider your normal operation a hazard to human health? (required)

Yes

No

Please enter any comments or explanations below:

Name: (required)

Phone Number: (required)

Physical Address: (required)

Mailing Address (if different):

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