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2. Cross-Connection Control/Backflow Survey Flow

   Please complete this survey form to identify which system(s) you have at your location to the best of your ability. This will help prevent contamination or pollution of our water sources. The intent is to update and identify all cross-connection devices within the Village in compliance with the Act, SECTION 19; 35 IAC 653.801.

4. Property Address with Device within Clarendon Hills, IL 60514*
5. Type of location*
   -- Select One --ResidenceBusiness
7. Property Owner Name*
8. Property Owner Phone
10. Property Owner Mailing Address
11. Property Owner Email
13. Check all that apply at your Property - do you have*

    1. Fire Sprinkler System
    2. Lawn Irrigation System
    3. Swimming Pool
    4. X-ray Machine
    5. Carbonated Beverage Machine

    1. Medical Equipment
    2. Photo Lab
    3. Large Commercial Boiler
    4. Commercial Ice Maker

    1. Cooling Tower
    2. Hose Aspirator for Spray Chemicals
    3. Water Tank Truck Filling Station
    4. None
15. Check all that apply

    1. The business at this location uses chemicals (beauty salons, Medical, etc)
    2. There is equipment hooked directly to the waterline at this address.
    3. There are backflow assemblies present at this property. (List below)
19. Assembly #1 - location

    i.e. (basement/ irrigation/pool)

20. Make and Model #
22. Size
23. Serial #
27. Assembly #2 - Location

    i.e. (basement/irrigation/pool)

28. Make and Model#
30. Size
31. Serial #
33. Additional Devices/Information (if needed)
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field