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Cross-Connection Control Survey: Residential

  1. State Law requires the public water system to survey their consumers not less than once every five (5) years.

    Completing & returning this Form, fulfills the State of Nebraska DHHS Regulation Title 179 requirement.

    Failure to complete and return this Report Form to the City of Columbus, may warrant a disconnection of water service by the Columbus Wastewater Collection / Utility Division that must perform an on-site inspection before restoring service.

  2. Account number can be found on bill or in address area of Cross-Connection Control Survey letter. Account Number Format: 123-12345-12

  3. 1. Private well that is connected to household plumbing?

  4. If Yes, is it protected by a testable backflow preventer?

  5. 2. Swimming pool or hot tub?

  6. If Yes, is it protected by a testable backflow preventer?

  7. 3. Water softener?

      1. If Yes, is it protected by a testable backflow preventer?

      2. 4. Underground lawn irrigation system?

      3. If Yes, is it protected by a testable backflow preventer?

      4. 5. Outside threaded faucet(s) or yard hydrant(s)?

      5. If Yes, is it protected by a testable backflow preventer?

      6. 6. Chemical Sprayers connected to garden hoses?

      7. If Yes, is it protected by a testable backflow preventer?

      8. 7. Boiler heat or water to air heat pump?

      9. If Yes, is it protected by a testable backflow preventer?

      10. 8. Photo lab, chemical, medical, or other lab facility?

      11. If Yes, is it protected by a testable backflow preventer?

      12. Leave This Blank:

      13. This field is not part of the form submission.