Village of Fox Lake
Sewer and Water Department
Cross-Connection/Backflow Survey

Mailing Address

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* 1. Mailing Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Property Address

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* 2. Property Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

What is your water account number?

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* 3. What is your water account number?

Is your property a residence or business?

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* 4. Is your property a residence or business?

Describe the nature of your business

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* 5. Describe the nature of your business

Do you have any of the following items at your property?

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* 6. Do you have any of the following items at your property?

Fire Sprinkler System

Lawn Irrigation System

Boiler (not a water heater)

Commercial Ice Maker

Swimming Pool

BUSINESSES ONLY - Do you have any of the following at your property?

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* 7. BUSINESSES ONLY - Do you have any of the following at your property?

Farm Equipment

Hose Aspirator for spraying chemicals

Medical Equipment

Water Tank Truck Filling Station

Photo Lab

Cooling Tower

Carbonated Beverage Machine

Chemicals, such as those used for a medical facility or spa/salon

Equipment hooked directly to waterlines

Are there any backflow assemblies present at your property?

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* 8. Are there any backflow assemblies present at your property?

Yes

If yes, please select the Manufacturer

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* 9. If yes, please select the Manufacturer

Ames

Conbraco

Febco

Hersey

Watts

Wilkins

Other

If yes, please enter the assembly information below

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* 10. If yes, please enter the assembly information below

Model # (909, 975, 825, etc.)

Serial Number (found on name plate)

Type (RP, DC, PVB, SVB)

Size (1", 2", 6", etc.)