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.
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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