Cross-Connection Information

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

1. Do you currently have a backflow preventer at your property? *

Yes

No

2. Do you have any of the following on your property? *

A. Sprinkler/Irrigation System

B. Pool (permanent above or below ground)

C. Hot Tub

D. Well, pond, or other auxilliary water system

E. Other potential cross-connection to the Public Water Supply (Explain below)

F. None of the above

3. If you are not required to have a backflow preventer and you answered "YES" to Question 1, do you plan to remove the backflow preventer or keep it in place?

Keep

Remove

I checked "NO" on Question 1

Confirmation *

I affirm that the information provided in response to this survey is truthful and accurate to the best of my knowledge.