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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.
Account number can be found on bill or in address area of Cross-Connection Control Survey letter.
Account Number Format: 123-12345-12
1. Private well that is connected to household plumbing?
If Yes, is it protected by a testable backflow preventer?
2. Swimming pool or hot tub?
3. Water softener?
4. Underground lawn irrigation system?
5. Outside threaded faucet(s) or yard hydrant(s)?
6. Chemical Sprayers connected to garden hoses?
7. Boiler heat or water to air heat pump?
8. Photo lab, chemical, medical, or other lab facility?
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