Cross Connection Questionnaire Form for MULTIPLE TENANTS You MUST fill out THIS form if you have multiple tenants. Is this a residential or commercial property? (required)Residential Commercial If commercial, please specify business name: (If more than one, please fill out the field below with your multiple tenant information) (required) Please enter your multiple tenant information in this box. Please include Unit #, Business Name, Type of Business, and Description of Water Use for each tenant. Are you renting or do you own this property? (required)Rent Own Your water meter serves how many homes? (Residential Properties)? (required) Your water meter serves how many buildings? (Commercial Properties: If more than one please ensure you have filled out the text box above with your multiple tenant information). (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) (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? (required)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 (required) 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 If yes, please provide: Manufacturer, Serial Number, and Model Number (required) Type of device(s) and/or assembly(s): (required)Reduced Pressure Principle Atmospheric Vacuum Breaker Pressure Vacuum Breaker Double Check Comments (required) Please notify the ELCO Water District 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 Print Your Name (required) Today's Date (required) Phone Number (required) Best Time to Call or Alternate Contact (required) Email (required) Mailing Address (required) Service 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 the District. 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.
