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Residential Cross-Connection Questionnaire

2. Residential Cross-Connection Questionnaire

3. 

5. Name*

6. Email Address*

8. Address*

10. City*

11. State*

12. Zip Code*

14. Phone Number*

15. Fax Number

19. Questionnaire

21. Cross Connections Program Link
    Click Here

23. Do you have a sprinkler system?

    1. Yes
    2. No
    3. Unsure

24. Has the PVB (pressure vacuum breaker) been tested?

    1. Yes
    2. No
    3. Unsure

    If NO, see city website for information on hot to get my back flow device tested.

26. Does hose bibbs have vacuum breakers?

    1. Yes
    2. No
    3. Unsure

27. Do you have a water assisted sump pump backup?

    1. Yes
    2. No
    3. Unsure

29. Do you have a boiler heating system?

    1. Yes
    2. No
    3. Unsure

30. Do you own the home?

    1. Yes
    2. No
    3. Unsure

32. Is there a private well?

    1. Yes
    2. No
    3. Unsure

33. Service line material

    1. Plastic
    2. Galvanized
    3. Unknown

    1. Lead
    2. Copper
    3. N/A

    See city website on information on how to ID a service line.

35. The City of Taylor will be contacting you to set up an appointment.

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field