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Cross-Connection Control Survey (Commercial/Non-Residential)
1.
Water Service Account Information:
Name of Business/Property/Building/Suite:
Property Address:
City of Aurora Water Account #:
Name on account:
Contact Person:
Date:
Phone/Email:
Primary Use of Property/Building/Suite:
2.
Water Uses - check all that apply:
Central Heating Boiler
Cooling Tower Supply
Air Conditioning Condenser Make-up
Process Water Make-up
Medical/Dental Equipment
Laboratory Equipment/Sinks
Food Service
Concrete Mixing
Irrigation
Equipment/Process Cooling
Fire Protection/Sprinkler System
Nursery/Garden Center
K-12 School/College/University
Assisted Living/Nursing Home
Hospital
Automotive/Vehicle Service
Funeral Home/Embalming Services
Morgue/Autopsy Services
Vehicle Washing Facility
Farming
Food Processing
Water Purification - RO; DI; etc
Other (please specify)
3.
List Known Testable Backflow Prevention Assemblies:
Manufacturer:
Model #:
Size:
Serial #:
Type of Equipment or Process Served:
Last Test Date:
4.
Additional Known Testable Backflow Prevention Assemblies:
Manufacturer:
Model #:
Size:
Serial #:
Type of Equipment or Process Served:
Last Test Date:
5.
Additional Known Testable Backflow Prevention Assemblies:
Manufacturer:
Model #:
Size:
Serial #:
Type of Equipment or Process Served:
Last Test Date:
6.
Additional Known Testable Backflow Prevention Assemblies:
Manufacturer:
Model #:
Size:
Serial #:
Type of Equipment or Process Served:
Last Test Date:
Thank you for completing the survey.
