Cross Connection Questionnaire Form Is this a residential or commercial property? (required)Residential Commercial If commercial, please specify business name (if more than one business is serviced by one service connection; ie multi-unit commercial, please fill out the Cross Connection Questionnaire Form for Multiple Tenants under our Forms tab) Are you renting or do you own this property? (required)Rent Own If renting, please provide name and address of owner: Your water meter serves how many homes (Residential Properties)? (required) How many buildings? (Commercial Properties: (if more than one business is serviced by one service connection; ie multi-unit commercial, please fill out the Cross Connection Questionnaire Form for Multiple Tenants under our Forms tab), (required) Do you have any of the following? (check all that apply) (required) Swamp cooler connected to piping Hot tub (fills with a hose or automatic filler) Swimming Pool Underground sprinkler system Drip irrigation system Greenhouse Onsite water storage Cooling (Chillers) Solar System Water makeup lines (boiler, hydronic heating) Utility sink with threaded faucet (hose attachment) Fire sprinkler system Unknown, unidentifiable or complicated piping None Do you use any of the following? (Check all that apply) (required) Antifreeze flush kits with your automobile Insecticide sprayers (that attach to a garden hose) Darkroom or photo developing equipment Fill adapters for waterbed, fish tank or other None Does anyone on the premises use a portable dialysis machine? (required)Yes No Do you have a bathtub or hot tub that fills from the bottom or does not have an overflow drain or the fill spout is not above the tub rim? (required)Yes No Do you have a water softener or any other water treatment system connected to your drinking water supply? (required)Yes No Do you have auxiliary water supply (i.e. well, pond) on your premises? (required)Yes No Do you have livestock (i.e. horses, cows, etc.) that use a water trough? (required)Yes No Is the water piping that enters your home more than 10 feet above your water meter? (required)Yes No Does a creek, river, or spring run near your property? (required)Yes No If you answered "Yes" above, do you pump or draw water from this source?Yes No NA Do you have a booster pump, well pump, or any other type of water pump? (required)Yes No Do you receive irrigation water from a different source? (required)Yes No Do you have any other water using equipment on your property not mentioned above? (required)Yes No If yes, please describe Is water used for any of the following on your property? (required) Food preparation Manufacturing Processing Industrial None Do you have any backflow prevention device(s) and/or assembly(s) on any equipment at your site? (required)Yes No Unknown If yes, please provide: Manufacturer, Serial Number, and Model Number Type of device(s) and/or assembly(s): (required)Reduced Pressure Principle Atmospheric Vacuum Breaker Pressure Vacuum Breaker Double Check None Comments: Please notify ELCO if any of the above conditions change on your property such as remodeling, changes or additions to your water piping system. Your Signature (required) Confirm e-Signature Review Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signatures Phone Number (required) Best time to call or alternate contact (required) Email Address Today's Date (required) Mailing Address (required) Site Address (if different) (required) Please answer all of the above questions and return the questionnaire within 30 days. This form will be kept on file at ELCO. If you have any questions please call us at 970-493-2044. Per District policy, failure to comply with backflow questionnaires and/or on site surveys, can result in termination of water services. There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received. If you are having issues with the online form, please ensure you are answering all required questions. If you are still having issues, please contact anthonya@elcowater.org or joshm@elcowater.org to obtain a PDF copy of the form.
