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2. Date
4. Rent or Own

   1. Rent
   2. Own
6. Service Address
8. Phone
10. Is there a private well or other source of water supply at this address including wells for geothermal heating/cooling?

    1. Yes
    2. No
11. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
13. Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical lab at this address?

    1. Yes
    2. No
14. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
16. Is there a boiler system used to heat this address?

    1. Yes
    2. No
17. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
19. Is there an underground sprinkler system at this address?

    1. Yes
    2. No
20. Is there a backflow preventer in use to protect the public water supply?

    1. Yes
    2. No
    3. N/A
22. Is there a swimming pool or hot tub at this address?

    1. Yes
    2. No
23. If yes, is it filled using a garden hose faucet that has a vacuum breaker?

    1. Yes
    2. No
    3. N/A
25. Are there outside garden hose faucets or a utility sink that a garden hose can be connected to the faucet?

    1. Yes
    2. No
26. Has a vacuum breaker been installed on each faucet?

    1. Yes
    2. No
    3. N/A
28. Is there a water softener system at this address?

    1. Yes
    2. No
29. Is there an air gap between the hose and the drain?

    1. Yes
    2. No
    3. N/A
31. Are there other suspected backflow conditions at this address?

    1. Yes
    2. No
33. Please list any general questions or comments regarding drinking water quality or utility service.
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34. Submit

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