City of Rockford Cross Connection Survey

Cross Connection Survey - Please fill out a survey for each Rockford, IL property that you own.

The below survey must be completed by all water services connected to our public water supply. This survey will help us prevent accidental contamination of our drinking water. The purpose of this survey is to determine whether a cross-connection may exist at your home or business.

This survey is required by the Illinois Environmental Protection Agency, and must be completed by all water customers. Most modern plumbing systems have backflow devices built in (toilets, sinks, modern hose connections). Please be assured this is not necessarily an indication of any problems, but is required by the IEPA. Thank you for your cooperation.

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* 1. Is this address residential or commercial?

Residential

Commercial

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* 2. Do you have an underground Lawn Sprinkler System?

Yes

No

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* 3. Do you have a swimming pool or a hot tub?

Yes

No

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* 4. Do you have a fire sprinkler system?

Yes

No

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* 5. Do you have boiler or steam heat?

Yes

No

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* 6. Do you have a biological or chemical lab on site?

Yes

No

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* 7. Do you have dental or dialysis equipment on site?

Yes

No

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* 8. Do you have a water treatment system (other than a softener)?

Yes

No

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* 9. Do you currently have a backflow valve(s) at this location?

Yes

No

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* 10. 10. Service Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number