2. Date
4. Rent or Own

   1. Rent
   2. Own
6. Service Address
8. Phone
10. Is there a private well or other source of water supply at this address including wells for geothermal heating/cooling?

    1. Yes
    2. No
11. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
13. Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical lab at this address?

    1. Yes
    2. No
14. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
16. Is there a boiler system used to heat this address?

    1. Yes
    2. No
17. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
19. Is there an underground sprinkler system at this address?

    1. Yes
    2. No
20. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
22. Is there a swimming pool or hot tub at this address?

    1. Yes
    2. No
23. If yes, is it filled using a garden hose faucet that has a vacuum breaker?

    1. Yes
    2. No
    3. N/A
25. Are there outside garden hose faucets or a utility sink that a garden hose can be connected to the faucet?

    1. Yes
    2. No
26. Has a vacuum breaker been installed on each faucet?

    1. Yes
    2. No
    3. N/A
28. Is there a water softener system at this address?

    1. Yes
    2. No
29. Is there an air gap between the hose and the drain?

    1. Yes
    2. No
    3. N/A
31. Are there other suspected backflow conditions at this address?

    1. Yes
    2. No
33. Please list any general questions or comments regarding drinking water quality or utility service.
Leave This Blank:


34. Submit

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