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CROSS CONNECTION CONTROL SURVEY

Romeoville Public Works
Instructions:
Please complete the form in full.
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Contact Information

Resident/Tenant Name:
Property Owner Name, if different than:
Address:
Owner Address:
Phone Number:
Owner Phone Number:
Type of Property:
1. Residential
1. Commercial
1. Other
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Check all that apply:

Outside Hose Bibs
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Lawn Irrigation System
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Swimming Pool/Hot Tub
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Pond/Foundation
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Water Filter/Water Softener
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Water Powered Sump Pump
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Solar Heating System
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Boiler (for heat)
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Fire Protection Sprinkler
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Mop Sink/Laundry Sink w/threaded spigot
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Carbonated Drink Machine
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Commercial Ice Maker
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Medical Equipment
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Cooling Towers
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Chemicals-Commercial Soap Dispensers/Etc.
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Dry Cleaning Equipment
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Photo Development Equipment
1. Yes
1. No
Backflow Preventer?
1. Yes
1. No
Please provide a brief description of any other item connected to the water system at your property.
Existing Cross Connection Devices (Backflow Preventer or RPZ):
Serial No.
Size
Manufacturer
Model #
Online To: (Ex. Domestic, Irrigation)
Date of Inspection
Serial No.
Size
Manufacturer
Model #
Online To: (Ex. Domestic, Irrigation)
Date of Inspection
Serial No.
Size
Manufacturer
Model #
Online To: (Ex. Domestic, Irrigation)
Date of Inspection

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Cross Connection Control Survey (Backflow Device)

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