Cross-Connection Questionnaire

2. Nebraska Department of Health and Human Services Title 179 requires the completion of a Cross-Connection Survey for all water connections to a public water system every 5 years. We ask for your assistance in completing this survey. To meet the state requirements, 100% of City of Papillion water customers must return the survey. If you need assistance in filling out this form, or if you have any questions about cross connections, please call 402-597-2043. Thank you for your cooperation.
4. First Name*
5. Last Name*
7. Business Name
9. Email
10. Daytime Phone
12. Address*
14. City*
15. State*
16. ZIP Code*
18. Please answer the following questions:
20. 1. Do you have a lawn sprinkler system?*

    1. Yes
    2. No
    3. Don't know
22. 1a. If yes, it is protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
24. 2. Do you have a swimming pool or hot tub?*

    1. Yes
    2. No
    3. Don't know
26. 2a. If you fill it with a hose, does a hose bib vacuum breaker protect it?

    1. Yes
    2. No
    3. Don't know
28. 2b. If you fill it with a direct line, is it protected by a reduced pressure backflow preventer?

    1. Yes
    2. No
    3. Don't know
30. 3. Do you use a hose aspirator for spraying chemicals? (All hose connections should have a hose bib vacuum breaker.)*

    1. Yes
    2. No
    3. Don't know
32. 3a. If yes, is it protected by a hose bib vacuum breaker?

    1. Yes
    2. No
    3. Don't know
34. 4. Do you have a fire suppression system?*

    1. Yes
    2. No
    3. Don't know
36. 4a. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
38. 5. Do you have an ice machine?*

    1. Yes
    2. No
    3. Don't know
40. 5a. If yes, is the compressor water-cooled?*

    1. Yes
    2. No
    3. Don't know
42. 5b. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
44. 6. Do you have a post mix water carbonator?*

    1. Yes
    2. No
    3. Don't know
46. 6a. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
48. 7. Do you have a water-cooled compressor?*

    1. Yes
    2. No
    3. Don't know
50. 7a. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
52. 8. Do you have any biological, veterinary, photo, chemical, or medical labs/facilities at this address?*

    1. Yes
    2. No
    3. Don't know
54. 8a. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
56. 9. Are there any pumps hooked to the plumbing?*

    1. Yes
    2. No
    3. Don't know
58. 9a. If yes, please check all that apply:

    1. Fountain
    2. Pressure Booster
    3. Sewer
    4. Other (please list)
59. 9b. If other, please list:
61. 10. Are there any other water processes that you may have connected to the water system?*

    1. Yes
    2. No
    3. Don't know
63. 10a. If so, what type?

    1. Private Well
    2. Cooling Tower
    3. Water Filling Station
    4. Other (please list)
64. 10b. If other, please list:
66. 10c. Are chemicals used in the water?

    1. Yes
    2. No
    3. Don't know
68. 10d. If yes, is it protected by a testable backflow device?

    1. Yes
    2. No
    3. Don't know
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field