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Cross-Connection Questionnaire

  1. Nebraska Department of Health and Human Services Title 179 requires the completion of a Cross-Connection Survey for all water connections to a public water system every 5 years. We ask for your assistance in completing this survey. To meet the state requirements, 100% of City of Papillion water customers must return the survey. If you need assistance in filling out this form, or if you have any questions about cross connections, please call 402-597-2043. Thank you for your cooperation.

  2. Please answer the following questions:

  3. 1. Do you have a lawn sprinkler system?*

  4. 1a. If yes, it is protected by a testable backflow device?

  5. 2. Do you have a swimming pool or hot tub?*

  6. 2a. If you fill it with a hose, does a hose bib vacuum breaker protect it?

  7. 2b. If you fill it with a direct line, is it protected by a reduced pressure backflow preventer?

  8. 3. Do you use a hose aspirator for spraying chemicals? (All hose connections should have a hose bib vacuum breaker.)*

  9. 3a. If yes, is it protected by a hose bib vacuum breaker?

  10. 4. Do you have a fire suppression system?*

  11. 4a. If yes, is it protected by a testable backflow device?

  12. 5. Do you have an ice machine?*

  13. 5a. If yes, is the compressor water-cooled?*

  14. 5b. If yes, is it protected by a testable backflow device?

  15. 6. Do you have a post mix water carbonator?*

  16. 6a. If yes, is it protected by a testable backflow device?

  17. 7. Do you have a water-cooled compressor?*

  18. 7a. If yes, is it protected by a testable backflow device?

  19. 8. Do you have any biological, veterinary, photo, chemical, or medical labs/facilities at this address?*

  20. 8a. If yes, is it protected by a testable backflow device?

  21. 9. Are there any pumps hooked to the plumbing?*

  22. 9a. If yes, please check all that apply:

  23. 10. Are there any other water processes that you may have connected to the water system?*

  24. 10a. If so, what type?

  25. 10c. Are chemicals used in the water?

  26. 10d. If yes, is it protected by a testable backflow device?

  27. Leave This Blank:

  28. This field is not part of the form submission.