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Cross- Connection Control Reporting Form

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Cross-Connection Control Reporting Form

Cross-Connection Control Reporting Form

State law requires consumers of public water supplies to inspect their facilities not less than once every five years. Completing this form fulfills that requirement!

 

Completion of this form is a condition of water service!

REPORTING FORM FOR THE WATER SYSTEM OF DAVID CITY
490 E ST., PO BOX 191 - DAVID CITY, NE 68632

 

2023

Customer Name: 

Customer Address: 

  Select Yes or No
If you HAVE NOT MADE any plumbing changes in the past 5 years, please select 'No' and submit the survey.
If you HAVE made any plumbing changes in the last 5 years, please select 'Yes', and complete the survey before submitting.

1. Underground lawn irrigation system?

If yes, is it protected by a testable backflow preventer?
2. Swimming Pool or hot tub?

If yes, is it protected by a testable backflow preventer?

3. Photo, chemical, medical, or other lab facilities?

If yes, is it protected by a testable backflow preventer?

4. Private well or other source of water?

If yes, is it protected by a testable backflow preventer?

5. Boiler pump or water to air heat pump?

If yes, is it protected by a testable backflow preventer?

6. Garden hoses connected to possible contaminants?

If yes, is it protected by a hose bibb vacuum breaker?

7. Water softener?

If yes, is it protected by an air gap?

8. Booster pump?

If yes, is it protected by a backflow preventer?

If yes, does it have a low-pressure shut off switch?

If you have any questions please contact Gil Frey – 402-443-9332

PLEASE COMPLETE WITHIN 30 DAYS

 

Signature:   Date: 

 

Thank you,

This form will help prevent the accidental contamination of our drinking water

Failure to complete and return this form puts your water system in violation of State Health Department Regulation Title 179.

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