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Cross Connection Control Survey

  1. CROSS-CONNECTION CONTROL SURVEY

    The following form is to be used by water department personnel and/or by customers of the Village of Rantoul public water supply. Data from this form may b used to determine if the property should be inspected by a licensed plumber with a CCCDI certification to detect and correct any cross-connections found on the property.

  2. Residential: (Check all that apply)

  3. Kitchen:

  4. Bath:

  5. Other:

  6. Exterior: (Check all that apply)

  7.  

  8. Is/Are private well(s) physically connected to the water system?

  9. Commercial: (Check all that apply)

  10. Is/Are private well(s) physically connected to the water system?

  11. Leave This Blank:

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