Cross Connection Questionnaire Form

Is this a residential or commercial property? (required)

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)

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 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)

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)

Do you have a water softener or any other water treatment system connected to your drinking water supply? (required)

Do you have auxiliary water supply (i.e. well, pond) on your premises? (required)

Do you have livestock (i.e. horses, cows, etc.) that use a water trough? (required)

Is the water piping that enters your home more than 10 feet above your water meter? (required)

Does a creek, river, or spring run near your property? (required)

If you answered "Yes" above, do you pump or draw water from this source?

Do you have a booster pump, well pump, or any other type of water pump? (required)

Do you receive irrigation water from a different source? (required)

Do you have any other water using equipment on your property not mentioned above? (required)

If yes, please describe

Do you have any backflow prevention device(s) and/or assembly(s) on any equipment at your site? (required)

If yes, please provide: Manufacturer, Serial Number, and Model Number

Type of device(s) and/or assembly(s): (required)

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.

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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.