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)

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)

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 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)

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? (required)

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 (required)

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 (required)

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

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.

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