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Cross Connection Survey

Home Cross Connection Survey

Cross Connection Survey

Customer Name *

Account Number *

(As shown on water bill)

Date *

Service Address *

Address Line 1

City

State

Zip Code

Contact Phone *

Contact Email *

Please answer ALL questions listed in below section and submit survey to Rend Lake Conservancy District at your earliest convenience.

Survey Questions

Does this meter serve more than one residence or location? *

Yes
No

If yes, how many? *

Do you have a private well or alternative water source? *

Yes
No

If yes, is it connected to the plumbing system? *

Yes
No

Do you have a fire sprinkler system? *

Yes
No

Do you have a water softener or home water treatment unit? *

Yes
No

If yes, is it protected by an air gap? *

Yes
No

Do you have an irrigation or sprinkler system? *

Yes
No

If yes, is it connected to the plumbing system? *

Yes
No

Do you use a boiler or hot water system for heat? *

Yes
No

If yes, is the fill line permanently connected to plumbing system? *

Yes
No

Do you have a swimming pool, hot tub or jacuzzi? *

Yes
No

If yes, does it have a permanent submerged water fill pipe? *

Yes
No

Do you have livestock watering troughs or tanks? *

Yes
No

If yes, is the fill line protected by an air gap? *

Yes
No

Do you have a pressure booster pump connected to plumbing system? *

Yes
No

If yes, does it have a low-pressure shut off switch? *

Yes
No

Do you have yard hydrants or faucets which a hose can be attached? *

Yes
No

If yes, do you submerge the hose to fill a pool / hot tub / chemical tank or attach a chemical sprayer / pressure washer to it? *

Yes
No

If yes to any above, do you use a hose bibb vacuum breaker? *

Yes
No

Do you have a photo, chemical, medical or other lab facilities? *

Yes
No

Do you have any other equipment other than household appliances connected to your plumbing system? *

Yes
No

Do you have a testable backflow prevention assembly installed? *

Yes
No

If yes, what kind? (RPZ, Double Check, Other) *

Brand / Model Number *

Last Date Tested *

Signature *

Clear Signature

Date *

Contact Info

Rend Lake Conservancy District PO Box 907
11231 Marcum Branch Rd Benton, IL 62812
Admin Phone: (618) 439-4321
Admin Fax: (618) 439-2400
Water Billing: (618) 439-4321
Golf Complex: (800) 999-0977

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Developed by James Arthur Design Co.

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