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Welcome to the Fox River Grove, IL, Action Line
Today is Sunday, July 6, 2025.
Cross-Connection Control / Backflow Survey

Notice to Property Owners with Backflow Devices
IEPA Title 35 Section 653.801 requires all property owners with backflow devices to complete a survey. This survey will help prevent the contamination or pollution of our water resources. Please complete the form below to the best of your ability or consult a licensed plumber for assistance.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
Email:
* Daytime Phone: ()  –
* Address:
* City:
* State:
* ZIP:

Business Address
 
* Water / Sewer Account #
 
Please state your type of business (e.g., restaurant, dry cleaner, etc.)
 
Do you have any of the following items at your property? (check all that apply):







14
 
* Does your business use chemicals, such as a medical facility or a beauty salon?
 
* Do you have any equipment hooked directly to your waterlines?
 
* Are there any backflow assemblies present at your property?
 
If yes, how many? If yes, list / fill in the information below for each backflow assembly. The information requested can generally be found on the assembly name plate. You may also list any additional assemblies in the text box at the bottom of this form.
 
* Backflow Assembly Manufacturer (e.g., Ames, Conbraco, Febco, Hersey, Watts, Wilkins):
 
* Backflow Assembly Model # (909, 975, 825, etc.):
 
* Backflow Assembly Serial # (found on plate):
 
* Size (1", 2", 6", etc.):
 
* Type (RP, DC, PVB, SVB)
 
Please provide the same details (i.e. Manufacturer, Model #, Serial #, Size, Type, etc.) for each additional backflow assembly.
 

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Notes:

This form is also available to complete in paper on the Village website at foxrivergrove.org/cross-connectionsurvey

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