Cross-Connection Control Survey Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Nebraska's Safe Drinking Water Act requires public water systems to implement an on-going cross connection control program. An important part of this program is public education. It is believed that a well-informed public will be more aware of the possibility of cross connections within their property and will take reasonable and sensible precautions to avoid creating cross connections on their property.

Email *

Name (Last, First): *

Business Name (if applicable):

Address: *

Account Number: *

Your Account Number is shown on your utility bill or you may contact City Hall at 402-694-6992 for assistance.

Is this a Commercial or Residential water service? *

Commercial

Residential

Is there an underground lawn irrigation system installed and/or in use? *

Yes, it is protected by a testable backflow preventer

Yes, it is NOT protected by a testable backflow preventer

Yes, but it is not in use

Is there a water softener installed and/or in use? *

Yes, it is protected by an air gap

Yes, it is NOT protected by an air gap

Yes, but it is not in use

Is there a private well located and/or in use on this property? *

Yes, it is used for underground lawn irrigation system only and has no physical connection to the city water system.

Yes, it is our primary domestic water source and has no physical connection to the city water system.

Yes, but it is not in use and has no physical connection to the city water system.

Is there a swimming pool or hot tub installed and/or in use? *

Yes, it is protected by a testable backflow preventer

Yes, it is NOT protected by a testable backflow preventer

Yes, it is not in use

I have completed the above survey truthfully and to the best of my knowledge listed all water uses at my facility that could potentially create a hazard to the public water supply. *

YYYY

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms