Cross-Connection/Backflow Survey

Nebraska Department of Health, Title 179 Regulations require that every facility connected to a public water supply be surveyed for cross-connections every five years.
This regulation requires the "customer" to complete this survey and report the results to the local water provider.
Please fill out this online survey and submit to fulfill this requirement.
Thank you.
If you have any questions, please call Robert Thompson at 308-324-5995 during business hours or email rthompson@cityoflex.com

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1. Customer's Name? (Required.)

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2. What is the name of the person answering this survey? (Required.)

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3. Business Name at this address? (if applicable)

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4. Site Address as listed on postcard or bill? (Required.)

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5. Contact Phone Number?  (Required.)

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6. What is the water service used for at this address? (Required.)

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7. Is there a backflow prevention device at this address?

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8. Do you have a water softener?

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9. Do you have an underground lawn sprinkler system?

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10. Do you have a swimming pool or hot tub?

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11. Do you have a private well on the property?

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12. If you do have a private well, is it used for drinking water?

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13. Do you use a water to air heat pump for heating your home?

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14. Do you use radiator or steam heat for heating your home?

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15. Do you have a soap dispenser hooked to your plumbing?

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16. What is the water line coming into your house made of?

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