Cross Connection Control Survey

2. 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.

   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.

4. First Name

5. Last Name

7. Address1

9. City

10. State

11. Zip Code

13. Name/Title of Person Conducting Survey

14. Phone Number

16. Residential: (Check all that apply)

18. Kitchen:

    1. Sink Faucet
    2. Sink Faucet w/Sprayer
    3. Ice Maker
    4. Garbage Disposal

19. Comments

21. Bath:

    1. Lavatory
    2. Toilet
    3. Bathtub
    4. Hot Tub
    5. Bidet

22. Comments

24. Other:

    1. Boiler heat

25. How Many Boilers?

27. Exterior: (Check all that apply)

29.  

    1. Outside Faucets

30. How Many?

31. 1. Non-Freezing Type

32. How Many?

34. 1. Lawn Irrigation System (Permanent)

35. 1. Lawn Fertilizer System

37. 1. Private Well(s)

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

    1. Yes
    2. No
40. Commercial: (Check all that apply)

42. 1. Lavatory

43. How Many?

44. 1. Deep Sinks

45. How Many?

47. 1. Boilers

48. How Many?

49. 1. Outside Faucets

50. How Many?

52. 1. Lawn Irrigation (Potable)

53. How Many?

54. 1. Lawn Irrigation System (Permanent)

55. How Many?

57. 1. Mixing Tanks w/ Overhead Fill Line

58. How Many?

59. 1. Mixing Tanks w/ Bottom

60. How Many?

62. 1. Watering Troughs

63. How Many?

64. 1. Bulk Water Salesman

65. How Many?

67. 1. Water-Cooled Air Conditioning System

68. How Many?

69. 1. Sitz Baths

70. How Many?

72. 1. Fire Protection Systems: Embalming Facilities (Mortuaries)

73. How Many?

75. 1. Private Well(s)

76. How Many?

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

    1. Yes
    2. No
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

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