Basic Information

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Basic Information

Business/Account Name:	Account Number:
Service Address:

Are the backflow device(s) listed on the mailed letter correct?

Are the backflow device(s) listed on the mailed letter correct?

Yes

No - Explain If other, type text here.

For all Yes answers, specify whether the device is protected with a testable backflow preventer.

Is there any other source of water, such as private well, at this address?

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For all Yes answers, specify whether the device is protected with a testable backflow preventer. Is there any other source of water, such as private well, at this address?

Yes - Protected

Yes - Not Protected

No

Do you have a swimming pool or hot tub filled by a direct water line?

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Do you have a swimming pool or hot tub filled by a direct water line?

Yes - Protected

Yes - Not Protected

No

Do you have a lawn sprinkler system?

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Do you have a lawn sprinkler system?

Yes - Protected

Yes - Not Protected

No

Do you have a hot water or steam boiler(s) (not water heater)?

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Do you have a hot water or steam boiler(s) (not water heater)?

Yes - Protected

Yes - Not Protected

No

Do you have a cooling tower?

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Do you have a cooling tower?

Yes - Protected

Yes - Not Protected

No

Do you have a photo lab, medical, biological, veterinarian or farm equipment, or any other chemical or medical labs or facilities at this address?

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Do you have a photo lab, medical, biological, veterinarian or farm equipment, or any other chemical or medical labs or facilities at this address?

Yes - Protected

Yes - Not Protected

No

Do you use a hose aspirator for spraying chemicals?

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Do you use a hose aspirator for spraying chemicals?

Yes - Protected

Yes - Not Protected

No

Do you have a fire suppression system?

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Do you have a fire suppression system?

Yes - Protected

Yes - Not Protected

No

Do you have a water truck or tank water filling station or pipe?

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Do you have a water truck or tank water filling station or pipe?

Yes - Protected

Yes - Not Protected

No

Do you have a water cooled compressor?

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Do you have a water cooled compressor?

Yes - Protected

Yes - Not Protected

No

Do you have a post mix carbonator?

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Do you have a post mix carbonator?

Yes - Protected

Yes - Not Protected

No

Do you use yard hydrants on your property?

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Do you use yard hydrants on your property?

Yes - Protected

Yes - Not Protected

No

Select if any pumps are hooked to the plumbing. If other, please list.

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Select if any pumps are hooked to the plumbing. If other, please list.

	Fountain	Pressure Booster	Sewer	Other	List other	None
Pump	Select if any pumps are hooked to the plumbing. If other, please list.	Select if any pumps are hooked to the plumbing. If other, please list.	Select if any pumps are hooked to the plumbing. If other, please list.	Select if any pumps are hooked to the plumbing. If other, please list.	Select if any pumps are hooked to the plumbing. If other, please list.	Select if any pumps are hooked to the plumbing. If other, please list.

Select the main type of business activity.

Select the main type of business activity.

Manufacturing

Medical Facility

Mechanic

Nursing Home

Office

Retail

Restaurant

Multi-unit Housing

Hotel

School

Other (please list) If other, type text here.

To my knowledge, these questions are accurate

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To my knowledge, these questions are accurate

Contact Name	Phone Number
Date (mm/dd/yyyy)

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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