Untitled Design

Village of Bloomingdale


Cross Connection Control Survey

THIS SURVEY IS REQUIRED BY THE ILLINOIS ENVIRONMENTAL PROTECTION AGENCY AND MUST BE COMPLETED BY ALL VILLAGE WATER CUSTOMERS

 

PLEASE COMPLETE THE SURVEY BY SEPTEMBER 30, 2023
 

If you have questions about the Village’s Cross-Connection Control Device Program or the Cross-Connection Control Survey, please contact the Public Works – Water Production Division at (630) 671-5800.
* Water Account Number
0/50
* Contact Name
0/50
* Service Address
0/250
* Phone # & Email Address
0/50

PROPERTY USE
RESIDENTIAL:
0/250
COMMERCIAL:
0/250

CROSS-CONNECTION CONTROL DEVICE INFORMATION

List EACH Cross-Connection Control (backflow prevention) device present on your property & INCLUDE the following information:

  1. SERIAL #
  2. MANUFACTURER
  3. MODEL
  4. SIZE
  5. APPLICATION/USE
Please list below:
0/500

Common Applications: Irrigation, Fire System, Domestic (at meter), Chemical Feed, Soap Dispenser

POTENTIAL CROSS-CONNECTION INFORMATION

Check YES or NO to common cross-connection conditions that may be present on residential or commercial properties: 
* Alternate water source (well)
If yes, is the source connected to Village Water Service?
* Swimming Pool/hot tub/whirlpool/jacuzzi
If yes, is a filler system connected to a Village Water Service
* Lawn/landscape irrigation system
If yes, is the lawn/landscape irrigation system connected to a Village Water Service
If the system is NOT connected to Village Water Service, please give source:
0/50
* Fire sprinkler / suppression system
* Water pressure booster pump
* Boiler / heat exchanger (not water heater)
* Detergent / soap injector system
* Solar heating system

Residential Users: once you have completed the above portion, please scroll to click the "Submit Survey" button. Commercial Users: please complete the additional section below and then click the "Submit Survey" button.

**THIS SECTION IS FOR COMMERCIAL USERS ONLY**

Check YES or NO to other conditions that may also be present:
Water cooled equipment / condensers / cooling tower
Soft drink dispenser / commercial ice maker
Water softener / treatment system
Shampoo sink / bowl
Medical / dental equipment (sterilizer, dialysis, x-ray, etc)
Chemical feed system
If yes, please provide details:
0/250
Pressure washer system
Industrial fluid / process system
If yes, please provide details:
0/250
Steam equipment
Photo processor / processing lab
Commercial car wash / wash rack facility
Truck / tanker fill station / equipment
Yard hydrants / outside hose-bibs

Once you have completed the survey, please click the "Submit Survey" button below. Thank you!
Submit Survey
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