Residential Cross Connection

July 1, 2025

2nd Notice

Residential Cross Connection Control Reporting Form 2nd Notice

State law requires consumers of public water supplies to inspect their facilities not less than once every five years. Completing & returning this form fulfills that requirement! Completion of this form is a condition of water service!

Name
Service Address/Addresses associated with NCU's water system
1) Do you have an underground lawn irrigation system?
** If YES, is it protected by a testable backflow preventer?
2) Do you have a swimming pool or hot tub?
** If YES, is it protected by a testable backflow preventer?
3) Do you have photo, chemical, medical or other lab facilities?
** If YES, is it protected by a testable backflow preventer?
4) Do you have a private well or other source of water?
** If YES, is it protected by a testable backflow preventer?
5) Do you have a boiler or use a water to air heat pump?
** If YES, is it protected by a testable backflow preventer?
6) "Garden Hoses" Do you connect possible contaminants to your garden hose?
** If YES, do you have a hose bib vacuum breaker?
7) Do you have a water softener?
** If YES, is it protected by an air gap?
MM slash DD slash YYYY
Thank you for taking time to fill out this form, it will help prevent the accidental contamination of our drinking water