Cross Connection Questionnaire Form Is this a residential or commercial property? (required)ResidentialCommercialIf 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)RentOwnIf 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 pipingHot tub (fills with a hose or automatic filler)Swimming PoolUnderground sprinkler systemDrip irrigation systemGreenhouseOnsite water storageCooling (Chillers)Solar SystemWater makeup lines (boiler, hydronic heating)Utility sink with threaded faucet (hose attachment)Fire sprinkler systemUnknown, unidentifiable or complicated pipingNoneDo you use any of the following? (Check all that apply) (required)Antifreeze flush kits with your automobileInsecticide sprayers (that attach to a garden hose)Darkroom or photo developing equipmentFill adapters for waterbed, fish tank or otherNoneDoes anyone on the premises use a portable dialysis machine? (required)YesNoDo 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)YesNoDo you have a water softener or any other water treatment system connected to your drinking water supply? (required)YesNoDo you have auxiliary water supply (i.e. well, pond) on your premises? (required)YesNoDo you have livestock (i.e. horses, cows, etc.) that use a water trough? (required)YesNoIs the water piping that enters your home more than 10 feet above your water meter? (required)YesNoDoes a creek, river, or spring run near your property? (required)YesNoIf you answered "Yes" above, do you pump or draw water from this source?YesNoNADo you have a booster pump, well pump, or any other type of water pump? (required)YesNoDo you receive irrigation water from a different source? (required)YesNoDo you have any other water using equipment on your property not mentioned above? (required)YesNoIf yes, please describeIs water used for any of the following on your property? (required)Food preparationManufacturingProcessingIndustrialNoneDo you have any backflow prevention device(s) and/or assembly(s) on any equipment at your site? (required)YesNoUnknownIf yes, please provide: Manufacturer, Serial Number, and Model NumberType of device(s) and/or assembly(s): (required)Reduced Pressure PrincipleAtmospheric Vacuum BreakerPressure Vacuum BreakerDouble CheckNoneComments: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-SignatureReview Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signaturesPhone Number (required)Best time to call or alternate contact (required)Email AddressToday'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...SubmitThank 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.