Cross Connection Survey


Please check the following that best describes the use of water at your residence.

 

  Typical water usage, such as bathrooms, household laundry ordishwashing appliances, and outside faucets.  (If this is the only usage that applies to your residence, please sign, date, 
and return.)

Is there any other source of water, such as a private well at this address?   (Y)  (N)

If yes, is it protected by a reduced pressure backflow preventer?               (Y)  (N)

Is there a swimming pool or hot tub at this address?                                         (Y)  (N)

If the pool is filled with a hose does it have a hose bib vacuum breaker?   (Y)  (N)

If the pool is filled by a direct water line, is it protect by a reduced Pressure backflow preventer?    (Y)   (N)

Is there an underground lawn irrigation system at this residence?               (Y)   (N)

If yes, is it protected by a reduced pressure backflow preventer?                (Y)   (N)

Is there a photo lab, medical, biological, veterinarian, or farm equipment, or any other chemical or medical lab or facilities at the address?      (Y)   (N)

If yes, is it protected by a reduced pressure backflow preventer?                (Y)  (N)

Is there any other water supplied equipment on the property not mentioned above?     (Y)  (N)

If yes please explain: _

 

    Name:  

Address: 

Contact # 

                  

      Existing Backflow preventer information

 

Manufacturer: 

 

Serial #            

 

Model:              

Size:                  

Location:           

If backflow prevention devices are installed on your plumbing, fire protection or lawn irrigation system, they are required by State of Tennessee Department of Environment and Conservation Division of Water Supply to be tested annually and copies of the test reports be maintained on file with the City of Munford Water Dept. If you do not have current copies of the test reports on file with us, please attach copies of the test(s) to this survey

                                    

 Signature of person completing survey: Date 

                                                                 

           
Any questions concerning this Survey please email Justin Barkelew at jbarkelew@munford.com