Cross Connection Survey 2018

CLARK-EDGAR RURAL WATER DISTRICT

Cross-Connection Control Survey

 This form MUST be completed and returned by July 1, 2018

 

All water suppliers are required by law to conduct a cross-connection control survey at least every two years. The last survey by Clark-Edgar Rural Water District was in 2016. Therefore, it is imperative that all customers again complete and return to us the following information.

__________________________________________________________________________________________________________________________________

STEP 1:

Account No.: ________________                 I own this property ______________              I rent this property _________________

Name: ___________________________________________________________________ Phone No.: _____________________

Address: __________________________________________________________              City: _______________    State: ______

Service Address if different from above: ________________________________________________________________________

 

CONNECTED to the District Water Supply: __________________    NOT CONNECTED_____________________

IF YOU HAVE A METER, BUT HAVE NOT YET CONNECTED TO THE SERVICE, PLEASE MARK “NOT CONNECTED” AND CONTINUE TO STEP 4; IF CONNECTED, PLEASE CONTINUE TO STEP 2.

 

STEP 2:

Water used for: Residence: ___________    Farm Operation: _____________               Commercial: _________   Industrial: _________

Other: (explain) ___________________________________________________________________________________________

Number of persons in household: ____ Size of service line (this is not our line it’s the line from your meter to home or business): ______

Type of plumbing in your home or business: Copper: _____     PVC/PEX: _______ Galvanized: ________       Combination: ______

Are all connections from your previous source of water completely separated from the lines supplying water from the Water District?

Yes _________    No __________

If you have cattle watering or any other types of fountain facilities on your property, does a proper air gap exist? A safe air gap means the minimum distance of a water inlet or opening above the maximum water level or overflow rim in a fixture, device, or container to which public water is furnished shall be at least two (2) times the inside diameter of the water inlet pipe, but shall not be less than one inch and need not be more than 12 inches.

Yes ________      No __________   I have no such devices ___________

Do you have a lawn sprinkling system installed? Yes __________        No _________              If yes, are proper backflow prevention devices installed? Please list any devices attached to your system other than normal household plumbing, such as outside hydrants, cattle watering facilities, fountains, or other appurtenances. ______________________________________________________________

Do you have a swimming pool? Yes ________          No __________   Approximate number of gallons it holds: ______________

Are all outside hydrants AWWA approved (no drain back type hydrants)? If drain back hydrants are installed, do they have the proper backflow prevention devices installed? Yes________       No________        I have no hydrants ___________

Does your water meter serve more than one residence? Yes_________               No__________

STEP 3: If you have Commercial or Industrial property, please complete Step 3; otherwise, please go to Step 4.

If commercial or industrial property, does your water meter have a RPZ (reduced pressure zone) backflow prevention device?

Yes ___     No ___           If yes, date installed ________________________, date last inspected __________________________.

___________________________________________________________________________________________

STEP 4:

I hereby certify that the above information is true and correct to the best of my knowledge and belief.

Signature: ______________________________________________      Date: _______________________

Print Name: ____________________________________________________________________________

If you have any questions or comments concerning the water service, please use the reverse side to respond.

THANK YOU FOR TAKING TIME TO COMPLETE THIS SURVEY. IT IS GREATLY APPRECIATED. YOU MAY RETURN IT WITH YOUR WATER PAYMENT.