Cross Connection Survey

Dear Water Customers,

The purpose of this survey is to determine whether a cross-connection may exist at your home or business. 
 

What is a Cross Connection?
A Cross Connection is any actual or potential connection between your drinking water and any non-potable source that results in contamination of the water distribution system.

What is Backflow?
Backflow occurs when the water in your pipes goes in the opposite direction of normal flow. There are two conditions that cause backflow:

  • Backpressure - when the pressure in your pipes is greater than the pressure in the water distribution system.
  •  Backsiphonage - when there is a sudden reduction of pressure in the water distribution system that causes fluids (water, chemicals, etc.) from your pipes to be sucked into the water distribution system.

The Illinois Environmental Protection Agency (IEPA) and the Illinois Department of Public Health (IDPH) are responsible for enforcing cross-control regulations.

This survey is required by the IEPA, and must be completed by all water customers.  We thank you for your cooperation on this matter.  If you have any questions, please contact City Hall at (618) 533-7625.

  

  

  

The PDF below may be completed and emailed into our office, or the open form fields may be filled out and will be submitted directly to our office.

Section 1: Location Information:
Customer Name:
Business Name at location (if applicable):
Account Number:
*Service Address:
Phone Number:
Email Address:
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Section 2:
*Types of Use:
RESIDENTIAL
COMMERCIAL
MEDICAL
INDUSTRIAL
GOVERNMENTAL
AGRICULTURAL
OTHER
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What industrial chemicals are used on the premises?:
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Section 3:
Do you have any other source of water such as private well, pond, lake, tank, bay, cistern, reclaimed water?:
Yes
No
***If yes, does it connect to the City's system?:
Yes
No
Are there backflow prevention devices installed on the premises?:
Yes
No
--If yes, please provide a copy of the test results by fax to (618) 532-4534 or by email to kaenke@cityofcentralia.org:
Is there an outdoor hydrant and/or outdoor faucet on the property?:
Yes
No
***If yes, which one?:
Outdoor Hydrant (out in the yard)
Outdoor Faucet (side of the building)
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All threaded hose connections are REQUIRED by the Illinois Environmental Protection Agency and the Illinois Plumbing Cod to have a HOSE VACUUM BREAKER. These are available at most hardware and plumbing supply dealers.:
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Section 4:
Do you have any of the equipment listed below on the premises? - Please check all that apply:
Autoclave (Doctor/Hospital - Disinfect Instruments)
Baptismal Fountain/tub
Bidet
Boiler
Car Wash Facilities
Chemical Feeder/Sprayer
Cooling Tower
Commercial Air Conditioning Equipment
Dishwasher
Drinking Fountains
Fertilizer Sprayer
Fire Sprinkler System
Grease Trap
Hot Tub
Industrial Fluid System
Lawn Irrigation System (Sprinkler)
Photo Processor
Power Flush Toilets
Pressure Booster (Placed where water comes into building)
Soap Injector
Soft Drink Dispenser
Steam Equipment
Sterilizer
Swimming Pool
Truck or Tank Filling
Water Cooled Equipment
Weedicide Sprayer
Buried Fuel Tanks
Water Softener
Recirculating Hot Water Furnace
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**THE CITY IS REQUIRED TO PROVIDE AN INVENTORY OF OUR CUSTOMER''S WATER SERVICE LINE TYPE. WE ARE ASKING YOU TO PROVIDE THE BELOW INFORMATION SO WE CAN BEGIN TRACKING THE DIFFERENT SERVICE LINE TYPES FOR THE EPA:
Section 5: What type of pipe do you have coming into your house?:
COPPER
GALVANIZED
LEAD
PLASTIC
OTHER
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Section 6: The information provided in this survey is an accurate and current description of the water system at this address:
Name of person completing this form:
Date:


* - denotes required field