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2. 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.

4. Customer Name*
6. E-Mail Address
8. Service Location*

   Can be found on your City of Columbus Utility Bill in the Billing Information section.

10. Account Number*

    Account number can be found on your City of Columbus Utility Bill.
    Account Number Format: 123-12345-12

12. Do you have any of the following at your home?
14. Private Well*

    1. Private well that is connected to household plumbing?

    1. Yes

    1. No
15. Private Well: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
17. Pool*

    2. Swimming pool or hot tub that is connected to household plumbing?

    1. Yes

    1. No
18. Pool: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
20. Softener*

    3. Water softener?

    1. Yes

    1. No
21. Softener: Test Backflow

    If Yes, is it protected by an air gap at the discharge hose?

    1. Yes

    1. No
23. Irrigation System*

    4. Underground lawn irrigation system that is connected to household plumbing? (not on a well)

    1. Yes

    1. No
24. Irrigation System: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
26. Threaded Faucet(s)*

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

    1. Yes

    1. No
27. Threaded Faucet(s): Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly or Hose Bib Vacuum Breaker?

    1. Yes

    1. No
29. Chemical Sprayer*

    6. Chemical Sprayers connected to garden hoses?

    1. Yes

    1. No
30. Chemical Sprayer: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
32. Boiler*

    7. Boiler heat or water to air heat pump?

    1. Yes

    1. No
33. Boiler: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
35. Lab Facility*

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

    1. Yes

    1. No
36. Lab Facility: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

    1. Yes

    1. No
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field