2024 Cross-Connection Control and Backflow Survey
This survey is REQUIRED by Ohio Administrative Code 3745-95-03 to determine whether there are actual or potential cross-connections to the consumer's water system through which contaminants could backflow or create a health hazard to the public water system.
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This form MUST be completed, or an ON-SITE inspection will be scheduled to determine if the plumbing system is in compliance. 
Account Name: *
Business Name:
Service Address: *
Account Number (if you have multiple accounts, please complete a survey for each account):
Phone Number: *
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