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2. In order to protect the City of Edwardsville's water supply from potential cross-connections, we are conducting a survey, as required by the Illinois Environmental Protection Agency, to determine if there are any hazardous conditions that could affect our drinking water. Answering "yes" to any of the survey items below indicates that a cross-connection may be present. The Illinois Department of Public Health requires annual inspections of all active backflow devices to protect from contamination. The City of Edwardsville is taking an active role in protecting the water supply.
   
   If you have had an inspection, please attach it with this survey if it has not already been submitted. Please be aware that this survey is for the current calendar year. Previous year survey submissions will not be considered as compliance. Non-compliance may result in your water being shut off until this survey is submitted.
   
   We appreciate you taking the time to complete the survey.
   
   If you have questions regarding the survey please contact the City of Edwardsville Public Works Department at 618-692-7535.
4. Account Number
5. Property Address
7. Type of Use *(Check all that apply)*

   1. Agricultural
   2. Commercial
   3. Government

   1. Industrial
   2. Residential
   3. Other
8. Please Specify
10. Do you have any other source of water, such as a private well, pond, lake, tank or reclaimed water that is connected to the public water supply?*

    1. Yes

    1. No
11. Are there any backflow prevention devices installed on the premises? (This does not include devices installed on the City water meter or outside water/garden hose). *

    1. Yes

    1. No
13. Has the device been tested?

    1. Yes

    1. No
14. Please provide a copy of the test results.

    May also be faxed to 618-692-7505, or mailed to 200 E Park Street, Edwardsville, IL 62025

16. Do you have a permanent in-ground lawn irrigation system installed on your property? (This does not include lawn water devices attached to a garden hose).*

    1. Yes

    1. No
17. Do you have a sump pump on your property?*

    1. Yes

    1. No
19. Does it connect to the City Sewer?

    1. Yes

    1. No
20. Does it have a water back up?

    1. Yes

    1. No
22. Do you have a swimming pool and/or hot tub?*

    1. Yes

    1. No
23. Is the pool / hot tub filled by a permanent connection to the water system?

    1. Yes

    1. No
25. Is your facility heated by a boiler?*

    1. Yes

    1. No
26. Do you have any of the equipment listed below on the premises?

    1. Baptismal Fountain / Tub
    2. Car Wash Facilities
    3. Chemical Feeder
    4. Fire Sprinkler System
    5. Industrial Fluid System
    6. Outdoor Yard Hydrant (a Plumbing Fixture Which Stands Upright Out of the Ground)
    7. Photo Processor
    8. Pressure Booster
    9. Shampoo Bowl
    10. Soap Injector
    11. Soft Drink Dispenser
    12. Steam Equipment
    13. Sterilizer
    14. Temporary Service
    15. Truck or Tank Filling Equipment
    16. Water Cooled Equipment
    17. Water Softener

    Check All That Apply
28. Commercial Properties
    This section should only be filled out by Commercial Properties. Please skip this section if you are a single family residential location.
30. Do you have industrial air conditioning equipment on the premises?

    1. Yes

    1. No
31. Does the equipment have an air washer on the premises?

    1. Yes

    1. No
33. Does the equipment have a condenser washer on the premises?

    1. Yes

    1. No
34. Do you have an industrial grease trap on your property?

    1. Yes

    1. No
36. Vacuum Breakers
    The Illinois Environmental Protection Agency and the Illinois Department of Public Health require hose vacuum breakers to be attached to all outdoor faucets. These devices protect the plumbing system from being contaminated by any substance which might enter the water hose (lawn fertilizer, herbicide, soap, ect.). Hose vacuum breakers are available at most hardware stores or through your local plumbing contractor.
38. Comments Regarding the Suvey
    Your comments are important in the cross-connection control program. Use this space for any comments or address corrections.
40. The information provided in this survey form is an accurate and current description of the water system at this address.
    Please type your name as confirmation of the person completing the survey.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field