Single Connection
Hazard Assessment Questionnaire

Please complete the questionnaire below so that we can determine the level of

cross-connection protection your service connection requires

Property Owner First and Last Name*

Street Number and Name*

City, State, Zip*

Phone/Cell Number

Email (optional)

Do you have any of the following on your property? (check all that apply)

In-ground irrigation

Drip irrigation system

Private well (in use)

Private well (not in use)

Private well (disconnected/capped/not in use)

Above ground storage tank(s)

Swimming pool

Spa/Hot Tub

Fire suppression sprinklers with chemical or anti-freeze injection capability

Fire suppression sprinklers without chemical or anti-freeze injection capability(water only)

Photo Lab

Sewage Booster Pump

Boiler

Sump Pump

None of the above

If you have a well, is it directly connected to your house,? (even if it has a bypass valve)

Yes

No

Unknown

Do you have a Backflow Assembly Installed on your property?

Yes

No

Unknown

If "Yes" What type of Backflow Assembly do you have?

Double Check (DC)

Reduced Pressure Principle (RP)

Unknown

Date of last Backflow Assembly Test

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