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.
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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 __________________________.
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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.