Question Title

* 1. Name

Question Title

* 2. Address that is on the postcard or letter...

Question Title

* 3. Account Number

Question Title

* 4. What color is the paper survey you received in the mail?

Question Title

* 5. Is there a backflow prevention assembly at this address?

Question Title

* 6. If yes, when was the device installed?

Question Title

* 7. If there is a backflow prevention device, when was it last tested and who tested it?

Question Title

* 8. Do you have a private well on the property?

Question Title

* 9. Is your private well used for drinking water?

Question Title

* 10. Do you use a water source heat pump for heating your home?

Question Title

* 11. If you use radiator/steam heating in your home, are any chemical additives used? 

Question Title

* 12. Do you have any chemical or lab facilities on the property? (medical, biological, veterinary, etc.)

Question Title

* 13. Do you have any hose aspirators for spraying chemicals on the property?

Question Title

* 14. Do you have any soft drink dispensers or bar carbonation on the property?

Question Title

* 15. Do you have any hose bib connections on the property? (garden hose faucet)

Question Title

* 16. Do you have any swimming pools or hot tubs on the property?

Question Title

* 17. Do you have any soap injectors on the property?

Question Title

* 18. Do you have any truck or tank water filling stations on the property?

Question Title

* 19. Do you have an underground lawn sprinkler system on the property?

Question Title

* 20. Do you have any water cooled equipment on the property?

Question Title

* 21. Do you have a water softener on the property?

Question Title

* 22. Do you have any water storage tanks on the property?

Question Title

* 23. Are there any pumps hooked to your plumbing? If yes, what kind?

T